A CASE STUDY FOR HEPATIC ABSCESSA Case Study Presented to the Faculty Of the College of Nursing Capitol University, CDOC In Partial Fulfillment of the Subject: RLE 7 By: Abada, Joana Marie Z. Sogoc, Windel A. Soon, Richelle Anne B. Sosmeña, Vannessa M. Sugarol, Kristine Mae U. Sunico, Kennelyn A. Sumile, April Rose G. Supangan, Dan A. Supnet, Eden Rhea J. Tabasan, Robert Y. Tadlas, Bonimar R. Taganas, Ronna Marie R. Submitted to: Rick Wilson Bunao, RN Clinical Instructor January 2010 In d c n tro u tio The liver is subject to a variety of disorders and diseases. One is Abscesses which is caused by acute appendicitis; those occurring in the bile ducts may result from gallstones or may follow surgery. The parasite that causes amebic dysentery in the tropics can produce liver abscesses as well. Various other parasites prevalent in different parts of the world also infect the liver. Certain drugs may also damage the liver, producing jaundice. A common sign of impaired liver function is jaundice, a yellowness of the eyes and skin arising from excessive bilirubin in the blood. Jaundice can result from an abnormally high level of red blood cell destruction (hemolytic jaundice), defective uptake or transport of bilirubin by the hepatic cells (hepatocellular jaundice), or a blockage in the bile duct system (obstructive jaundice). Failure of hepatic cells to function can result from hepatitis, cirrhosis, tumors, vascular obstruction, or poisoning. Symptoms may include weakness, low blood pressure, easy bruising and bleeding, tremor, and accumulation of fluid in the abdomen. Blood tests can reveal abnormal levels of bilirubin, cholesterol, serum proteins, urea, ammonia, and various enzymes. A specific diagnosis of a liver problem can be established by performing a needle biopsy. Bacterial abscess of the liver is relatively rare. It has been described since the time of Hippocrates (400 BC), with the first published review by Bright appearing in 1936. In 1938, Ochsner's classic review heralded surgical drainage as the definitive therapy; however, despite the more aggressive approach to treatment, the mortality rate remained at 60-80%. The development of new radiologic techniques, the improvement in microbiologic identification, and the advancement of drainage techniques, as well as improved supportive care, have decreased mortality rates to 5-30%; yet, the prevalence of liver abscess has remained relatively unchanged. Untreated, this infection remains uniformly fatal. Prior to the antibiotic era, liver abscess was most common in the fourth and fifth decades of life, primarily due to complications of appendicitis. With the development of better diagnostic techniques, early antibiotic administration, and the improved survival of the general population, the demographic has shifted toward the sixth and seventh decades of life. Frequency curves display a small peak in the neonatal period followed by a gradual rise beginning at the sixth decade of life. Cases of liver abscesses in infants have been associated with umbilical vein catheterization and sepsis. When abscesses are seen in children and adolescents, underlying immune deficiency, severe malnutrition, or trauma frequently exists. G oals and O bjectives of the study 1. To have an in-depth understanding of the Hepatic abscess disease. 2. Give appropriate application of physical assessment to detect actual and potential health problems which are to be given priority 3. Promote health education in relation to the health condition of the patient. 4. To determine the proper intervention regarding the health care management on the presenting disease and its associated complication. History of Present Illness: One week before admission. A’s educational attainment was limited up to Grade 5 thus prompted him to work as a farmer in Balingasag. Misamis Oriental Sex: Male Age: 29 years old Height: 5 feet and 5 inches / 168cm Weight: 149 pounds/ 68 kilograms Occupation: Farmer Civil Status: Married Nationality: Filipino Religion: Roman Catholic Date of Admission: January 10. Thus finally consulted at Balingasag Medical hospital and was admitted as a case of urinary tract infection. Environmental and Psychosocial History: Mr. Patient a tolerated his condition and no consult done. He also added that he has been drinking alcoholic beverages mostly five bottles thrice a week. hence admitted. Misamis Oriental. patient A noted onset of moderate grade fever associated with chills and epigastric pain. Mr. He has no known allergies. He takes coffee occasionally for at least one glass per day. He was married to Mrs. A in 2000. He doesn’t exercise but plays basketball leisurely. A manages a small convenient store near their house. .C IE T P O IL L N ’S R F E Name: Mr. Mrs. Eventually referred at Northern Mindanao Medical Center. P stated that he has been a tobacco user for eleven years and smokes half to 1 pack per day. Personal. 2010 Admitting Diagnosis: Hepatic Abscess Chief Complaint: Intermittent epigastric pain. The couple have two daughters and all of them are still dependent on the family. the patient would still have recurrence of fever episodes and increasing abdominal pain. A Address: Balingasag. During the assessment. Two days prior to admission. burning 4. 5). with a GCS of 15. considerable in size. A showed cardiac rate of 67 beats Cardiac rate of 65 bpm. oxygen saturation per minute. with vein was not visible. A was sitting at the right side of his fowlers position. can motor maintain intact. Cardiovascular System Initial Assessment Final Assessment Mr. hoarse conscious still and with aware of of surroundings. no heart murmurs heard. 2010 Final Assessment: January 16. A was lying on his bed in a semi. oxygen saturation of 95%. place and Fully surroundings. 2010 General Survey Initial Assessment Final Assessment Mr. no numbness. Peripheral of 30. burning sensation reported. Wearing a 48 kilograms. Capillary refill on the right arm. with Glasgow Coma Scale functions intact. 46 kilograms. with pulse pressure of 2 seconds. or sensory numbness. Flat a precordial area. tingling or (GCS) of 14 (spontaneous eye opening. jugular vein was not visible. A was accompanied by his wife. surroundings. balance and stance for more than 5 no seconds when asked to stand. functions and localizes painful stimuli. auscultation. blood pressure of 120/90 mmHg taken with pulse pressure of 40. oriented and converses clearly.Blood pressure of 120/80mmH. motor functions . intact. Central Nervous System Initial Assessment Final Assessment conscious and aware of Alert and oriented to time. of 95%. were intact. 5 feet and 5 inches in white t-shirt and generally appears clean. patent Normal Saline Solution (PNSS) at 600 and infusing well at the left metacarpal milliliters level. height. fully fully conscious and aware voice. 5.Mr. communicates verbally person. and generally appears dusky. sensory and actively. minute. functions tingling sensation were reported. ongoing with intravenous fluid of PNSS at 900 level ongoing intravenous fluid of Plain running at 30 drops per minute. bed.Physical Assessment: Initial Assessment: January 14. running at 30 drops per vein. Mr. A was accompanied by his wife. Mr. on pulses with regular rate and rhythm. Jugular no evidence of bleeding. ambulatory. patent and infusing well at the left metacarpal vein. Pinkish nail bed. ventilator and endotracheal tube in place. no clubbing noted. with good elasticity. and percussion of abdomen as ordered by the physician. no palpation palpation and percussion allowed. wounds. he hematuria distended. Gastrointestinal System Initial Assessment Final Assessment inspection. Spine was ventrically aligned. chest wall intact. with regular rate and rhythm of peripheral pulses. . Mr. Integumentary System Initial Assessment Final Assessment Uniform deep brown skin color except No pressure sores. wounds. no barrel chest noted. no other lesions noted. skin sprang back to previous state when pinched. no tenderness noted. bladder not added that he urinated thrice in the last two hours and failed to measure it. symmetrical chest expansion. no that he had no difficulty in urinating. Lung expansion symmetrical as well tactile fremitus. bladder not distended. Urinary System Initial Assessment Final Assessment No urinary catheter noted urine output No urinary catheter noted. Respiratory System Initial Assessment Final Assessment Head of the bed elevated to 35-45 Breathing pattern with respiratory of 24 degree angle. abrasions or in areas exposed to the sun. rounded. abdomen was Abdomen was uniform in color. with evidence of cpm. nasal flaring as noted. A reported was 100mL for the last two hours. use of accessory muscles were evident. abrasions or other lesions noted. Still with no difficulty of breathing. no mechanical attached.capillary refill of 3 seconds. pressure sores. With a respiratory rate of 30 endotracheal and mechanical ventilator cycles per minute. pale nail beds. Still no Upon uniform in color. noted. midline. Spine is in contracture in muscles and tendon.Musculoskeletal System Initial Assessment Final Assessment Equal size on both sides of the body. A expressed that it was hard for Patient has understood the nature of his him to be hospitalized and experienced illness but still eager to get well and to difficulties due to his disease. equally strong in no weakness or paralysis. was able to turn from side to side. recover soon since he misses the quiet However. tremors was not evident. no joint pain or stiffness.gait is coordinated. he was hopeful that he can environment at home. muscles were firm at rest with equal strength on each body side. recover very soon as he modifies and strengthens his lifestyle by complying with his medical regimen. no tenderness noted. Psychosocial System Initial Assessment Final Assessment Mr. no deformities. no muscle tone and strength. full range of motion. Full range of motion. His support system was not adequate tho. . ANATOMY AND PHYSIOLOGY LIVER . The Liver: Anatomy and Functions Anatomy of the liver: The liver is considered the largest organ in the body and is located in the upper righthand portion of the abdominal cavity. including the following: • • oxygenated blood flows in from the hepatic artery nutrient-rich blood flows in from the hepatic portal vein The liver holds about one pint (13 percent) of the body's blood supply at any given moment. beneath the diaphragm. Some of these functions are to: • Manufacture (synthesize) proteins. E. the liver is a dark reddishbrown organ that weighs about 3 pounds. The hepatic duct transports the bile produced by the liver cells to the gallbladder and duodenum (the first part of the small intestine). and process (metabolize) fats. The liver has a multitude of important and complex functions. Shaped like a cone. These lobules are connected to small ducts that connect with larger ducts to ultimately form the hepatic duct. and K. which are used as the source for the sugar (glucose) in blood that red blood cells and the brain use Form and secrete bile that contains bile acids to aid in the intestinal absorption (taking in) of fats and the fat-soluble vitamins A. including albumin (to help maintain the volume of blood) and blood clotting factors Synthesize. and intestines. store. right kidney. D. • • • . both of which are made up of thousands of lobules. The liver consists of two main lobes. including fatty acids (used for energy) and cholesterol Metabolize and store carbohydrates. There are two distinct sources that supply blood to the liver. and on top of the stomach. hormones. When bile acids are converted or "conjugated" in the liver. The liver also contains small amounts of Vitamin C. potassium. substances needed to help blood coagulate. cholesterol. proteins. The liver also has an important role in vitamin storage. Liver cells protect the body from toxic injury by detoxifying potentially harmful substances. they become bile salts. These substances are converted in the liver into glycerol and fatty acids. The liver also plays a major role in excreting cholesterol. are both produced by the liver. Bilirubin is the main bile pigment that is formed from the breakdown of heme in red blood cells. the potentially harmful biochemical products produced by the body. When the reticuloendothelial system breaks down old red blood cells. bilirubin. The broken-down heme travels to the liver. they can be excreted from the body in the urine. bilirubin is one of the waste products. The liver plays an important role in metabolizing nutrients such as carbohydrates. Bile is a combination of water. through a process known as ketogenesis. the liver synthesizes glucose from proteins or fats to maintain blood glucose levels. and galactose are converted to glycogen and stored in the liver.• Eliminate. sodium. from which urea is formed and excreted in the urine. phospholipids. and lipoproteins. and environmental toxins • The liver synthesizes and transports bile pigments and bile salts that are needed for fat digestion. The conjugation process in the liver converts the bilirubin from a fat-soluble to a water-soluble form. This "free bilirubin" is a lipid soluble form that must be made water-soluble to be excreted. The liver also produces the anticoagulant heparin and releases vasopressor substances after hemorrhage. Bilirubin production and excretion follow a specific pathway. and fats. Prothrombin and fibrinogen. . Through the process of glycogenolysis. the liver breaks down stored glycogen to maintain blood glucose levels when there is a decrease in carbohydrate intake. By making toxic substances more water soluble. such as bilirubin from the breakdown of old red blood cells and ammonia from the breakdown of proteins Detoxify. alcohol. cholesterol. Liver cells also chemically convert amino acids to produce ketoacids and ammonia. Digested fat is converted in the intestine to triglycerides. The liver synthesizes about 50 grams of protein each day. most of the body's Vitamin D stores. where is it secreted into the bile by the liver. and drugs from the body. primarily in the form of albumin. phospholipids. by metabolizing and/or secreting. and Vitamins E and K. and chloride. The liver helps metabolize carbohydrates in three ways: • • • Through the process of glycogenesis. glucose. Primary bile acids are produced from cholesterol. drugs. bile acids. by metabolizing and/or secreting. High concentrations of riboflavin or Vitamin B1 are found in the liver. fructose. Through the process of gluconeogenesis. 95% of the body's vitamin A stores are concentrated in the liver. bile pigments. o.Predisposing Factor: Age: 29 y. monocytes and other WBCs enter the area Increased blood flow into the area Decreased albumin . and other chemicals (chemical “alarms”) Blood vessels dilate Capillaries become “leaky” Neutrophils. histamine. Gender: Male Chronic alcohol drinker (for almost 11 years) Occupation: Farmer Poor hygiene P th p y io g a o h s lo y Precipitating Factor: Unsanitary food handing Infection of liver Activation of inflammatory response Release of kinins. bid. Increased hydrostatic pressure Redness • Heat Fever Fluids and proteins leave the blood vessel going to interstitial spaces of tissue Edema Paracetamol 500mg. 10. PO Increased metabolic rate of tissue cells Pain Malaise Swelling Abdominal pain (RUQ) Tramadol 50 mg. 2010) • WBC-20. IVTT Medical Management: • metronidazole q8h. q8h.9 x 10^3/uL . IVTT • ciprofloxacin 500mg 1 tab. PO Failure of inflammatory mechanism Severe infection Hematology Report: (Jan.Decreased oncotic pressure. dead pathogens) Pus are walled off the liver HEPATIC ABSCESS Blockage of bile duct Prevents bile from entering small intestine Bile accumulates and backs-up into the liver Pressure on liver cells Hepatomegaly . broken-down tissue cells.Uncleared area of debris Sac of pus (mixture of dead neutrophils. Proteins enter bloodstream Bile salts and bile pigments enter bloodstream Circulation of bile pigments Jaundice Lab Result: Protein (+2) Circulation of proteins Enters kidney circulation Icteric sclera Protein in urine (Proteinuria) . 22 REFERENCE (4.3 cm seen in its medial aspect. result to experience nausea. vomiting. Pancreas is unremarkable.2 (135 – 148)mmol/L ULTRASOUND REPORT January 13.LABORATORY RESULTS Blood Chemistry Dr. DIAGNOSIS: 1. POSSIBLY AN ABCESS 2.) COMPLEX. Its wall is not thickened. A complex hypoechoic mass measuring 9. % INTERPRETATI ON Normal Normal Low potassium resulting to have muscle weakness. The right hepatic lobe is uremarkable. 2010 Tentative Diagnosis: FINDINGS: The left lobe is enlarged. muscle aches. headache and malaise. Creatinine Potassium = 0.6 cm x 8. Sarmiento 01-13-10 RESULTS Blood urea nitrogen = 15.73 = 3.5 – 5.8 cm x 7. Gallbladder is normal in size. and muscle cramps.2) mgs.6 – 1. HYPOECHOIC MASS.) NON – REMARKABLR ULTRASOUND FINDINGS IN THE GALLBLADDER AND PANCREAS . No intraluminal mass or lithiasis seen. MEDIAL ASPECT OF THE LEFT HEPATIC LOBE.27 (0.3)mmol/L Sodium = 134.4) mgs. Hyponatremia.6 – 23. % (3. INTERPRETATION: Hypoechoic on ultrasound means dark. in liver at times there is inhomogenous fat deposition which appear which appears bright and areas of sparing appear dark or hypoechoic and can times mimic mass on ultasound URINALYSIS REPORT January 14. within the range from 1. a risk for infection Normal. globulins.015 Excess sweating.030 CHEMICAL PROPERTIES: proteins Glucose trace Normal negative Normal SEDIMENT/MICROSCOPIC EXAMINATION Moderate 2-3 4-6 Few Epithelial cells Puss cells (WBC) Red blood cells Bacteria Normal Kidney or bladder injury or UTI UTI . and Bence-Jones protein at low concentrations Alkaline.5 1. 2010 INTERPRETATION PHYSICAL PROPERTIES: Color yellow Clarity Hazy pH Specific gravity 7.003 – 1. also a sign that patient is not been drinking enough liquids Detected albumin. an infection. 2010 INTERPRETATION PHYSICAL PROPERTIES: Color Clarity Dark yellow Cloudy pH Specific gravity 5. proteins Glucose negative SEDIMENT/MICROSCOPIC EXAMINATION 4-6 Puss cells (WBC) Red blood cells Coarsely granular Mucus threads 2-3 0-2 few .URINALYSIS REPORT January 10. infection in either the upper or lowe urinary tract Kidney or bladder injury or UTI high salt concentration Mucus threads are usually present in small numbers. alteration of liver function Normal Pyuria. normal normal May have kidney damage.030 CHEMICAL PROPERTIES: +2 Liver problems or jaundice Excessive cellular material or protein in the urine Acidic. Increased numbers are indicative of chronic inflammation of the urethra and bladder.0 1. 1 29.5 – 10.0 % % % % 17. 2010 HEMATOLOGY REPORT TEST WHITE BLOOD CELS RED BLOOD CELLS HEMOGLOBIN HEMATOCRIT RESULT 14.4 12.0 12.0 INTERPRETAION Infection Anemic Normal signal conditions such as anemia.0 – 47.2 – 5.400 Normal Normal Infection infection or an inflammatory process in the body Normal --Normal .0 – 2.5 – 35.4 – 76.1 3. bone marrow problems.0 Basophils (%) Bands/scabs (%) PLATELET REMARKS 0.0 – 10.0 – 16.9 33.2 43.0 – 98.0 150 .0 31.8 0.0 – 2.5 1.6 fL Pg g/dL % fl fL 82.0 18.0 – 17.0 – 12.FECALYSIS January 10.8 10.0 1.0 9.0 – 31.0 27. 4.0 15.0 32.0 37.0 264 % % 10^3/uL 0.0 8.2 4.0 – 10.8 UNIT 10^3/uL 10^6/uL g/dL % REFERENCE 5.4 – 48.0 – 3.68 11.5 15. 2010 INTERPRETATION PHYSICAL CHARACTERISTIC Color and character yellow consistency watery PARASITIC ORGANISM Negative for any amoeba and other intestinal parasitic ova Normal Diarrhea Normal January 13.2 66. dehydration Normal Normal Normal Normal Normal Normal MCV MCH MCHC RDW-CV PDW MPV DIFFERENTIAL COUNT Lymphocyte (%) Neutrophil (%) Monocyte (%) Eusinophils (%) 89.0 8. 0 150 .0 – 3.0 – 16.0 UNIT 10^3/uL 10^6/uL g/dL REFERENCE 5.0 31.0 9.7 221 % % % % 10^3/uL 4.5 – 35.5 1.0 – 98.2 – 5.0 – 47.0 INTERPRETATION Infection Normal poor diet/nutrition or malabsorption Normal Normal Normal Normal ------Risk for infrction Elevated levels of neutrophils may occur when the body is fighting a flu or other infection infection ------Normal HEMATOCRIT MCV MCH MCHC RDW-CV PDW MPV DIFFERENTIAL COUNT Lymphocyte (%) Neutrophil (%) 40.400 HEMATOLOGY REPORT January 10.4 % fL Pg g/dL % fl fL 37. 4.0 33.0 % % 17.0 27. 2010 .0 82.0 – 2.0 – 17.4 – 76.TEST WHITE BLOOD CELS RED BLOOD CELLS HEMOGLOBIN RESULT 20.0 0.0 7.4 – 48.0 – 12.8 30.0 – 10.0 – 2.0 8.0 – 16.2 43.4 14.0 – 31.5 – 10.50 13.0 1.9 4.0 12.3 82.4 89.2 Monocyte (%) Eusinophils (%) Basophils (%) Bands/scabs (%) PLATELET 10. . some OTC drugs.” as verbalized by the patient Objective: • Capillary refill of about 3 seconds assessed • Pallor • Muscle wasting Goals and Objectives: Long term goal: After 2 days of nursing care. Rationale: Evaluation: Goals partially met. the patient will be able to demonstrate lifestyle changes to improve circulation. Balanced intake and output Nursing Interventions: Independent: • • • • Assist patient in ROM exercises (exercises prevent venous stasis) Proper positioning of patient. Respiration within normal range b. Short term goal: After 4 hours of nursing care. change every 2 hrs. (This promotes optimal ventilation and perfusion) Teach patient breathing relaxation technique (to improve oxygen demand of patient) Elevate head of bed. vitamins containing potassium. mineral oil or alcohol when taking anticoagulants. as evidenced by: a. the patient will be able to demonstrate increased perfusion as appropriate. as evidenced by: • 24 cpm • Capillary refill 2 sec • Demonstrate proper breathing relaxation technique . Rationale: To increase gravitational blood flow Encourage use of relaxation techniques Rationale: To decrease tension level • Dependent: • Emphasize importance of avoiding use of aspirin.NURSING CARE PLAN Nursing Diagnosis Ineffective Tissue Perfusion related to interruption of venous flow Assessment Data Subjective: “Maglisod ko ug ginhawa bisan maghigda. NURSING DIAGNOSIS Ineffective breathing pattern related to pain ASSESSMENT DATA (SUBJECTIVE AND OBJECTIVE CUES Subjective: “Usahay galisod ko og ginhawa maam” as verbalized Objective: . if recommended by the physician (promotes respiration) EVALUATION Goals partially met .respiration within normal range from 30 cpm to 20 cpm b.do not use of accessory muscle Long term goal: At the end of 1 day of nursing intervention the patient will: .absence of nasal flaring c.The patient’s respiration is 24 cpm .Pallor .Use of accessory muscle .absence of nasal flaring and use muscle accessory .Have adequate ventilation as evidenced by: a.Nasal Flaring .Tachypnea RR = 30 .pain scale 10/10 GOALS AND OBJECTIVE Short term Goal: At the end of 30 minutes of nursing intervention the patient will: .demonstrate appropriate coping behavior NURSING INTERVENTION • Independent • Elevate head of bed or position patient in a semi fowler’s position (to promote physiological/psychological ease of maximal inspiration) • Encourage deep breathing exercise by using purse-lip technique (to take control of the situation) • Assist client in the use of relaxation technique like breathing exercise (to promote rest) • • • Provide comfort position to patient (to prevent uneasiness ) Ambulate patient and assist in exercise as tolerated (maximize patient’s level of functioning) Encourage adequate rest period between exercise (to prevent fatigue) Dependent • Administer analgesic. g. holds body. • • • . Acknowledge the pain experience and convey acceptance of client’s response to pain.”as verbalized. ASSESSMENT DATA: SUBJECTIVE CUE: “ Sakit akoang tiyan sa tuo dapit. R: pain is subjective experience and cannot be felt by others. as noted.NURSING CARE PLAN NURSING DIAGNOSIS: Acute Pain related to presence of pus in the liver.Observed evidence of pain Muscle guarding noted with pain scale of 10/10. OBJECTIVE CUES: . nurse’s presence) quiet environment. imaging and listening to calming music. Encourage also diversional activities. Provide comfort measures (e. • Observe nonverbal cues/pain behaviors (e. R: to distract attention and reduce tension. how the patient walks. R: to promote nonpharmacological pain management. Expressive behavior observed ( sighing ) Doctor ordered not to palpate patient abdomen GOALS AND OBJECTIVE: Short term goal: • After 30 minutes of nursing interventions. Determine patient’s acceptable level of pain/pain control goals. touch. use of heat/cold packs. which can mean constricted blood vessels) and other objective cues. and calm activities.g. facial expression.. Facial Grimace noted. Long term goal: • After 8 hours of nursing intervention. repositioning.. the patient pain will decreased from 10/10 to 5/10. R: observations may/may not be congruent with verbal reports or may be only indicator present when client is unable to verbalize. the patient’s pain will be relieved from 5/10 to 0. Instruct patient to encourage use of relaxation techniques such as focused breathing. NURSING INTERVENTIONS: • Accept client’s description of pain. cool fingertips/toes. sits. R: it may vary to individuals coping capabilities. as evidenced by: Pain scale of 5/10. as indicated. EVALUATION: GOALS PARTIALLY MET . . Notify the physician if regimen is in adequate to meet pain control goal. to maximum dosage. R: to maintain acceptable level of pain. as needed.• Administer analgesics. is 37. as ordered. Short term goal: After 1 hour of nursing care.0 • Administer medications as indicated to treat underlying cause. q4hrs for T≥38. Rationale: To prevent dehydration • Maintain bedrest. The patient’s temp. Objective: • • • • Increased body temperature (T= 37. including Escherichia coli Evaluation: GOALS MET.8°C to 37. Ciprofloxacin 500mg 1tab.Hyperthermia related to increased metabolic rate Assessment Data Subjective: “Sugod pa ko gihilantan atong pag-admit nako”. as verbalized by the patient. the patient will be able to display signs of wellness.NURSING CARE PLAN Nursing Diagnosis . . twice a day • Indication: For treatment of infections caused by susceptible gramnegative bacteria. Rationale: To reduce metabolic demands and oxygen consumption • Dependent: • Administer antipyretics.5C. paracetamol 500mg 1 tab.5. as evidenced by reduced body temperature from 37. Nursing Interventions: Independent: • Monitor vital signs. the patient will be able to identify contributing factors and importance of treatment.8°C) assessed Skin is warm and dry to touch noted Increased respiratory rate (RR= 30 cpm) assessed Firm skin turgor noted Goals and Objectives: Long term goal: At the end of 30 minutes. Rationale: To provide a baseline data Promote surface cooling by means of tepid sponge bath Rationale: To promote heat loss by means of evaporation • Discuss importance of adequate fluid intake. . • Increase fluid intake to 2-3 liters/ day. Rationale: To prevent nausea and vomiting. Rationale: To prevent constipation.5 • pale conjunctiva • Abnormal laboratory findings a. Objective: • Body mass index: 17.5.Imbalanced Nutrition: Less than body requirements related to increased metabolic demands. Rationale: To enhance food satisfaction and stimulate appetite. Nursing Interventions: Independent: • Provide small frequent meals. Dependent: • Use flavoring agents. • Served high fiber diet. patient will be able to demonstrate behaviors. lifestyle changes to regain and maintain appropriate weight.68 Goals and Objectives: Long term goal: At the end of 8 hours.NURSING CARE PLAN Nursing Diagnosis . RBC 3. Short term goal: At the end of 1 hours patient will be able to verbalized understanding of causative factors when known and necessary interventions. Rationale: To implement interdisciplinary team management. . Collaborative: • Consult a dietitian/ nutritional team as indicated. Rationale: To manage fluid imbalanced. Weight of patient below normal range of body mass index 17. Assessment Data Subjective: " magsakit akong tiyan kung magkaon" as verbalized by the patient. Evaluation: Goals not met. R: To improve metabolism. • Encouraged exercise as tolerated like passive ROM. hypersensitivity to opioids. Route: IVTT Frequency: q8h . Overdose results in respiratory depression and seizures. CONTRAINDICATIONS Acute alcohol intoxication. NURSING RESPONSIBILITIES/ PRECAUTIONS Check the prescribed medication for 3 time on the first encounter. R> to make the patient prepare and know what to expect The med should be given in IVTT route according to the doctor R> Follow the doctor’s order as prescribed to the patient. Give first health teaching before giving the patient. DRUG ORDER Generic name: Tramadol hydrochloride Brand name: Ultram Classification: Analgesic Dosage: 50mg INDICATIONS Management of moderate to moderately severe pain. opioids. or psychotropic drugs. ADVERSE EFFECTS OF THE DRUG Seizures have been reported in patients receiving tramadol within the recommended dosage range. before and after withdrawing the med R> so that the medicine is properly checked according to the doctor’s prescription. hypnotics. concurrent use of centrally acting analgesics. Therapeutic Effect: Alters the perception of and emotional response to pain. Tramadol may not have prolonged duration of action and cumulative effect in patients with hepatic or renal impairment.Drug Study MECHANISM OF ACTION An analgesic that binds to mu-opioid receptors and inhibits reuptake of norepinephrine and serotonin reduces the intensity of pain stimuli reaching sensory nerve endings. CNS.DRUG ORDER Generic name: Metronidazole Brand name: Metronidazole Benzoate Classification: Antibacterial. Treatment of trichomoniasis. CONTRAINDICATIONS Hypersensitivity to other nitroimidazole derivatives. antibioticassociated pseudomembranous colitis (AAPC). severe treatment is stopped hepatic dysfunction. Therapeutic Effect: Produces bactericidal. bone and joints). Produces antiinflammatory and immunosuppressive effects when applied topically. inhibiting nucleic acid synthesis. amebiasis. appear. Question for hypersensitivity on metronidazole R> to determine if the med is applicable to patient. antiprotozoal. is Cautions: blood usually reversible if dyscrasias. Seizures occur ocassionally. R> to make the patient prepare and know what to expect The med should be given in IVTT route according to the doctor R> Follow the doctor’s order as prescribed to the patient. amebicidal. Give first health teaching before giving the patient. manifested as numbness and tingling in hands or feet. before and after withdrawing the med R> so that the medicine is properly checked according to the doctor’s prescription. ADVERSE EFFECTS OF THE DRUG NURSING RESPONSIBILITIES/ PRECAUTIONS Check the prescribed medication for 3 time on the first encounter. neurologic symptoms predisposition to edema. and trichomonacidal effects. Peripheral neuropathy. immediately after CNS disease. . INDICATIONS For treatment of anaerobic infection (skin and skin structures. antiprotozoal Dosage: 750mg Route: IVTT Frequency: q8h MECHANISM OF ACTION A nitroimidazole derivative that disrupts bacterial and protozoal DNA. lower respiratory tract. for ophthalmic administration: vaccinia. P. mirabilis. Cautions: renal impairment. E. P. and cerebral thrombosis may occur. H. bone and joint. typhoid fever febrile neutropenia. NURSING RESPONSIBILITIES/ PRECAUTIONS Question for hypersensitivity for the medicine R> since it will harm the patient Monitor for any dizziness. pneumoniae. interfering with bacterial cell replication. Shigella species. S. vulgaris. sinusitis. R> to determine client’s response to the med. CONTRAINDICATIONS Hypersensitivity to ciprofloxacin or other quinolones. and urinary tract infections. including photosensitivity (as evidenced by rash. cloacae. varicella. typhi including intraabdominal. blisters. influenzae. lower respiratory tract. infectious diarrhea. coli. headache. pephropathy. cardiopulmonary arrest.DRUG ORDER Generic name: Ciprofloxacin hydrochloride Brand name: Ciloxan Classification: Anti-infective Dosage: 500mg 1 tab MECHANISM OF ACTION A fluoroquinolone that inhibits the enzyme DNA gyrase in susceptible bacteria. K. visual changes. protastitis. seizures. those taking caffiene. pruritus. chest pain. Hypersensitivity reaction. edema and burning skin) have occurred in patients receiving fluoronolones. CNS disorders. Route: Oral Frequency: BID . Do not take with antacids R> since it could reduce or destroy the drug’s effectiveness. Therapeutic Effect: Bactericidal INDICATIONS For treatment of infections due to E. skin and skinstructure. ADVERSE EFFECTS OF THE DRUG Superinfection. tremors. Reduces volume and hydrogen ion concentration of gastric juice. Prevention of duodenal ulcer recurrence. elderly. Cautions: renal or hepatic impairment. NURSING RESPONSIBILITIES/ PRECAUTIONS Obtain baseline liver/renal function tests. INDICATIONS For short term treatment of duodenal ulcer. or when stimulated by food. ADVERSE EFFECTS OF THE DRUG Reversible hepatitis and blood dyscrasias occur rarely. CONTRAINDICATIONS History of acute porphyria. Therapeutic Effect: Inhibits gastric acid secretion when fasting. or insulin. caffeine. at night.DRUG ORDER Generic name: Ranitidine hydrochloride Brand name: Zantac Classification: Antiulcer Dosage: 150mg 1 tab Route: Oral Frequency: BID MECHANISM OF ACTION An antiulcer agent that inhibits histamine action 2 receptors of gastric parietal cells. R> to determine if the patient’s organ could metabolize the drug Assess mental status of the elderly R> to determine if the drug affects the mental state of the patient Inform or give health teachings to patient on what to expect after drug administration like headache R> so that the patient would be aware about the side effects that he would experience . antidote. NURSING RESPONSIBILITIES/ PRECAUTIONS Inform patient and SO that discomfort may occur with parenteral administration. dizziness. complaint of abdominal or back pain. INDICATIONS Antidote for hemorrhage induced by oral coagulants. Therapeutic Effect: Essential for normal clotting of blood. hypotension progressing to shock. facial flushing. rapid or weak pulse. antihemorrhagic Dosage: 1 ampule Route: IVTT Frequency: q24h MECHANISM OF ACTION A fat-soluble vitamin that promotes hepatic formation of coagulation factors I. II. ADVERSE EFFECTS OF THE DRUG A severe reaction (cramplike pain. VII. dyspnea. IX. increase in PR. CONTRAINDICATIONS Hypersensitivity. hypoprothrombinemic states due to vitamin K deficiency. cardiac arrest) occurs rarely just after IV administration. and X. rash diaphoresis. chest pain. R> to be aware what will be the expexted affect after administration of med Do not use OTC medication without physician’s approval R> this may interfer with platelet aggregation Assess for decrease in BP.DRUG ORDER Generic name: Vitamin K Brand name: AquaMEPHYTON Classification: Nutritional supplement. severe headache R> this may be evidence of hemorrhage . skin rashes.. NURSING RESPONSIBILITIES/ PRECAUTIONS The medication should be given in orally R> this is according to the doctor’s order. . Potentially Fatal: Very rare. liver damage.DRUG ORDER Generic name: Paracetamol Brand name: Boigesic Classification: Analgesics and Antipyretics Dosage: 500mg Route: Oral Frequency: PRN or q4h for temp. R> to determine if the patient is allergic to drug Intruct the patient/ give first health teaching before giving the patient. acute renal tubular necrosis. R> to make the patient prepare and know what to expect Give only the med for presence of fever or pain R> overdose could lead to drug-resistance Paracetamol exhibits For treatment of mild to analgesic action by moderate pain and peripheral blockage of fever. It produces antipyresis by inhibiting the hypothalamic heat – regulating center. leukopenia. Its weak anti-inflammatory activity is related to inhibition of prostaglandin synthesis in the CNS. pain impulse generation. agranulocytosis). allergic reaction.g. neutropenia. blood dyscrasias (e.380C MECHANISM OF ACTION INDICATIONS CONTRAINDICATIONS Hypersensitivity. Assess patient for any drug allergy to the medicine. thrombocytopenia. ADVERSE EFFECTS OF THE DRUG Nausea. • Explain the importance of maintaining fluid and electrolytes balance. Maintaining good personal hygiene. The risk is higher in people who have many abscesses. contributing factors. schedule. • Discuss and encourage proper techniques in preventing further infection and injury. Along with the procedures. vomiting. care and treatment. chills. & unintentional weight loss. Promoting proper skin and wound care. Tell the client and family members to maintain the ideal body weight of the patient. by weighting the client daily and record the result if necessary. loss of appetite.6 weeks). and route of administration of any prescribed drugs. • Discuss the proper use medication. dark urine. That’s why we stress the importance of the following: • Explain the disease process. Monitoring for fluid and electrolytes balance Assess intake and output. . and pain in right abdomen (more common) or through out the abdomen. If not. fever. • Teach signs and symptoms that require immediate medical attention.HEALTH TEACHINGS Treatment of hepatic abscess condition can be life-threatening in 10-30% of patients. Weigh patient daily. That’s why treatment usually consists of surgery or going through the skin with a needle or tube (percutaneous) to drain the abscess. Such as chalk-colored stool. as well as side effects to report to the physician or nurse. the patient will also receive long-term antibiotic therapy (usually 4 . nausea. Assess presence and extent of edema. life-threatening sepsis can develop. causes. because sometimes antibiotics alone can cure the infection. Encouraging patient to increase fluid intake. In order for the patient to understand his condition and for him to be able to participate in improving it. dosage. Explain the purpose. to perform many self-care activities as possible. Promoting hope Providing opportunity for patient to express feelings about self. Encouraging activity within prescribed limits but avoid fatigue. Encouraging good oral hygiene. Medicating patient as needed for pain. supportive environment • Tell the family to assist with coping in life-style and self-concept.Passes help the patient adjust to the home environment and to practiced self care activities at home and help the family adjust to living with patient and to any alterations in physical. Therapeutic passes . and let them explain to the patient how it benefits for him to be as independent as possible. Avoiding stress which can aggravate symptoms. Remind also the family members to support the patient in his activity of daily living. . and emotional functioning (after discharge). Providing calm. • Teach the family of how to promote comfort. Providing comfort measures and relaxation techniques. within his condition’s capacity. cognitive. Protecting from injury when carrying out activities. Maintaining good asepsis during treatments and procedures. Protecting patient from exposure to infectious agents. Tell also the family members to encourage the patient. Encouraging proper diet. Encouraging rest for fatigue. or any. prescribed route. painful abdomen. stretching and other form of activities that would help maintain joint mobility & enhance circulation >Avoiding strenuous activities. vomiting and seizures. Exercises Treatment: Very important treatment includes strict compliance to the prescribed medication most especially significance antibiotic of therapy and the nutritional supplements promoting healing of the damage liver cells and improves general nutritional status. Health teaching: With emphasis on: >compliance to medication regimen > importance of proper diet. prescribed time and as on how many days will it be consumed. >avoidance of alcoholic beverages > importance of immediate consultation whenever symptoms of complications or progression of disease occurs like. >regular exercises like walking. This will help the patient for fast recovery and prevention to further complication. and faster recovery . >importance of good hygiene >significance of adequate rest Out-Patient: Patient should return to the institution one or two-weeks after discharge for follow-up check-up on his physician for health assessment. trouble breathing all of the sudden.DISCHARGE PLAN Medications: Patient is advised to take all the medications prescribed by the physicians as to the prescribed dosage. whole-grain breads. Eating healthy foods may help him have more energy and heal faster. Spiritual: Significant others were reminded to continue offer emotional support to patient and help to strengthen his spiritual faith so that patient will both have spiritual and emotional outlet to avoid depression. low-fat dairy products.Diet: >Patient encouraged having adequate nutritional supplements. >Encouraged to eat variety of healthy foods such as fruits. . vegetables. beans. lean meat and fish. At a short period stay at (NMMC) Northern Mindanao Medical Center. it serves as a reminder to trust in ourselves and our God. We never fail to be concerned towards each other. we work together and care for each other.LEARNING EXPERIENCE As new day arises. in the end. reading. new trials are challenging us. You should not waste time doing senseless distractions. be wise and strengthen your faith. It is more than just a group. despite the harshness of reality. As our duty progresses. A few of us know the importance of living life positively. That is the beauty in our group. you are on your own. do good. we are always reminded not to be enticed with worldly matters. Although change does not happen overnight. testing every learning and knowledge we obtain in the previous days. One of this if we call it a trial is the challenge of making a case study on trisomy 21 disorder. After. yet. Life is great and beautiful and we realize it when we are open to learning and never are afraid to take challenges and opportunities that come along the way. we are family. but we should use our freedom wisely. you have to focus on it. handling cases and interactions are just a few that we have mastered. We should not give up. We should start making a move. temptation. We make our life. we have to put impact on every good thing that we do. It is where we put all of what we are in extreme preparation. it is a good feeling to know that you have controlled yourself and leading it to make a difference. brave enough to win success. There are many choices that surround us but it specifies on two questions: To do good? Or do it badly. Make life with less regrets. whether many will hinder our path. consequences that we have right now. Many may know if not all that this type of disorder is hard to accept in the parenting side. If you want your life to have an impact. difficulties. Medical ward. life may be short. Yes. we have established a great bond among our group mates. This Duty reminded us that life is too short to keep on committing the same mistakes all over again. we will realize that regardless of everything that is going on. Whatever trials. We have to be careful of our actions each day for the days are sometimes evil. We learn together. DOCTOR’S ORDER . it leads us to many channels. rather gain from your opportunities. we are student nurses on action. Monitor VS q2 hr. 12. D5NR 1l @40 gtts/min. Vita k 1 amp. Metronidazol 750 mg 3. 14 2010 9 am Pt.. 11. refer if with abdominal pain and severe hypotension D5LR 1L @ 20 gtts/min x 2 cycles Refer accordingly • Jan. present medications IVF TT: D5NR 1L @ 20gtts/min D5NR 1L @ 20gtts/min Refer accordingly For utz of HBT today for repeat Na. Creat. Avoid vasalva maneuver(straining.0 Tramadol 50mg IVTT q8 hrs. PNSS 1L @ 30 gtts/min. then 750 mg IVTT q 8 hrs. SGPT. 2010 s.K.1 week undocumented on and off fever with chils and nausea (+) epigastric pain Refer accordingly • ↓fever episode • Schedule for UTZ. BUN CBC with platelet Repeat PTPA-Partial Requests: 1. seen in the ward Continue present meds. 5. or any unusualiies and refers to MROD Refer accordingly Continue present meds. BUN. 2010 4:30 pm BP. K. Alk.100/60 HR 80 RR 20 Still with fver episodes (+) tenderness RUQ Jan. IVF TF: PNSS 1L @ 30gtts/min.• Jan. Tramadol 50mg IVTT q8 hr. Paracetamol PRN if 38 deg. stool exam Urea. Metronidazole 750 mg IVTT now. 2010 11:30 pm BP:120/80 HR:76 RR:20 Dec.HOT tomorrow AM pls.-given 1st done Watch out for severe abdominal pain. 10 2010 6pm BP 110/70 HR 80 RR 10 T 37 Start_____: PNSS 1L @ 60 gtts/min_ongoing IVF TF: 1. Ranitidine 100mg 1 tab. . Na. Phos. Celsius 6. poin RUQ area Jan. facilitate transport Cont. BID 4. Diagnostic: CBC with pH U/A. D5NR !L @ 40gtts/min. 13. K 1 am. IVTT now then Q 24 hr. • Jan. SOB. then q 4 hrs for T≥38. SGOT CXR: PAT UTZ: HBT Therapeutic: Paracetamol 500mg 1 tab now. Cipro 7 2. Ranitidine 150 mg 1 tab. BID Vit. 2. 2010 7am ↓abdominal pain Awke febrile 9:30 am (-) adbdominal pain Afebrile For possible aspirationof hepatic abscess today Pls. SGOT. x 3 cycle . Na . secure consult to procedure Pls. distress + flat abdomen. Alk phosphate Give tramadol Prn for pain Continue meds: IVTT D5LR !L @ 30gtts/min. soft + tenderness Non swollen abdomen as of examiner Will do UTZ. 16. IVTT D5LR 1L @ 30gtts/min x 2 cycle For referral to surgery Refer accordingly Pt seen and examined HX & PE received Lab and UTZ notedexamined and febrile noted in resp.. K. & chart IVTT D5LR 1L @ 30gtts/min D5LR 1L @ 30gtts/min ↑ IVF to 40 gtts( present IVF) Refer accordingly • 10:20 pm Awake. Q4hr then q4hr. SGPT. crea. PRN for nfever there after For repeat CBCOH. inform SROD once 3-way stop cock in available Give paracetamol nonce a day 1 tab.Check-epigastric pain and fever up to 40 hr UT2. ROPA. 15.consider abcess(liver) carrying heavy objects) and abdominal manipulation Monitor VSq 4hr. 2010 11:25 -afebrile -C/C -DAT 3pm For referral to surgery for abdominal evaluation if possible transfer of service Continue meds Refer accordingly • Continue meds. afebrile DHS. facilitate aspiration of hepatic abscess as ordered by SROD Pls. murmur UT2 noted Jan.aspiration of Hepatic abscess “emergency” Secure consent to procedures To secure 3-way stop To secure Epidoral needle for aspiration • Jan.