Case PresentationSurgical Ward

I. Introduction:

Colorectal cancer (also known as colon cancer, rectal cancer or bowel cancer) is when cancer develops in the colon or rectum (parts of the large intestine).[1] It is due to the abnormal growth of cells that have the ability to invade or spread to other parts of the body.Symptoms may include blood in the stool, a change in bowel movements, weight loss, and feeling tired all the time.

Most colorectal cancers are due to lifestyle factors and increasing age, with only a small number of cases due to underlying genetic disorders.Risk factors include: diet, obesity, smoking and not enough physical activity.Dietary factors that increase the risk include: red and processed meat as well as alcohol.[4] Another risk factor is inflammatory bowel disease, which includes Crohn's disease and ulcerative colitis.Some of the inherited conditions that can cause colorectal cancer include: familial adenomatous polyposis and hereditary non-polyposis colon cancer; however, these represent less than 5% of cases.It typically starts as a benign tumor which over time becomes cancerous.Bowel cancer may be diagnosed by biopsy during a sigmoidoscopy or colonoscopy. This is then followed by medical imaging to determine if the disease has spread. Screening is effective at decreasing the chance of dying from colorectal cancer and is recommended starting at the age of 50 and continuing until the age of 75. Aspirin and other non-steroidal anti-inflammatory drugs decrease the riskTheir general use is not recommended for this

Globally, colorectal cancer is the third most common type of cancer making up about 10% of all cases. In 2012 it resulted in 1.4 million new cases and caused 694,000 deaths. It is more common in developed countries where more than 65% of occur. It is less common in women than men.

II. Purpose/ Objective:

Learning Goal Student Centered Client CenteredSkills To put into action the skills that

we have learned in RLE into real life situation in handling the patient.

To be able to perform the skills needed for the patient effectively.

Knowledge To gain knowledge about the disease chosen.

For the patient and her relatives to gain knowledge about the disease

Attitude To be able to practice our communication technique in dealing with patient and her relatives.

To give the patient the immediate care needed that will help in the alleviation of her condition through providing rapport.

I. Biography :

a. Name: Patient Ab. Age: 39 years oldc. Sex: maled. Birthdate: September 9, 1974e. Address: Bagong Flores,Lupao Nueva Ecijaf. Marital Status: Marriedg. Address: Sta. Rosa Nueva Ecijah. Occupation: Housewifei. Religion: Roman Catholicj. Room/Ward: Female surgical Ward, Bed 1k. Date and time of Admission: June 21, 2013/ 3:45pml. Admitting Diagnosis:m. Final diagnosis: ascending colon adeno CAn. Chief Complaint:

The patient is complaining of abdominal distention few days prior to consultation.

IV. History of Present Illness:

The patient complained of abdominal distention few days prior to consultation. The condition started several weeks prior to admission as gradual abdominal distention. She had undergone explore lap on July 2009.

V. Past Medical History:

Last July 17, 2009, the patient was admitted at Eduardo L. Joson Memorial Medical Hospital due to a mass of the right lower quadrant of the abdomen. She was diagnosed of having an ileocecal mass and an operation was done which is explore laparotomy right hemicolectomy and total abdominal bilateral hysterosalphingo-ooperectomy last July 24, 2009(10am)

VI. Past Surgical History:She had undergone explore laparotomy right hemocolectomy and total abdominal

bilateral hysterosalphingo-ooperectomy last July 24, 2009(10am)

III. Allergies/ Medications:She has no allergies to any food and medication given to her upon hospitalization. The

following are the medications given to her during the course of treatment: Metronidazole 500mg q8 IV Metoclopramide 10mg/2ml TID Omeprazole 20mg 1tab OD per orem

Cefuroxime 500mg 1tab TID per orem Iberet Folic tab OD per orem Ranitidine 50mg q8 IV Ceftriaxone 1GM q8 IVP Catapres 75mcg q8 w/n NPO SL Ketorolac amp for pain IVP Nubain amp every 6 hours PRN for severe pain IVP

IV. Smoking, Alcohol, Substance Abuse :The patient is not a smoker and a drunker. She has never been engaged in taking any

abusive substance.

V. Social/ Work History:She is a full housewife she only uses to work inside their house in doing their household

chores and in taking care of her children.

VI. Family History:Upon taking the interview, she stated that her family has a history of hypertension only.

VII. Review Of System:

PATHOPHYSIOLOGY

Modifiable Non-modifiable

-High fat, low fiber -Age-Gender

Ingestion of Food Presence of recurrent tumor in ileocecal junction

Digested through mouth and stomach Immune response

Absorption of nutrients in WBC small intestine

Intestinal obstruction

Accumulation of fluid, gas and stomach content

Inability to excrete waste products Unable to defecate for 18 days

Extreme vigorous increased pressure peristaltic wave in the intestinal lumen

Reverse peristaltic Movement in venous and arterial inability to absorb compression of

capillary pressure water by the large right ureter Fecal excretion through NGT intestine middle 3rd

Impaired blood circulation Dehydration Impaired filtration

-Edema of right kidney-Congestion-necrosis slight kidney

enlargement Perforation

Peritonitis

VIII. Physical Examination

I. Vital Sign’s Temperature Pulse Rate Respiratory Rate Blood Pressure

Actual Findings36.6 degrees Celsius

75 bpm22 cbm

150/100 mmhgII. Level of Consciousness Conscious and Coherent

III. BODY PARTS NORMAL FINDINGS ACTUAL FINDINGS Scientific ExplanationA. GENERAL

APPEARANCEWith normal weight, afebrile, proportionality and symmetry

The patient’s weight is normal at her age with proportional body.

Normal

B. SKIN The color depends on race, ethnic background, complexion, sun exposure, and pigmentation tendencies.

Poor skin turgor Due to dehydration

C. HAIR Grows well, properly tied, no hair loss, with proper hair distribution

With proper hair distribution

Normal

D. NAILS Clean and pink in appearance.

Clean and Pink in appearance

Normal

E. SKULL AND HEAD

Normal cephalic, symmetrical facial structure, absence of tenderness over the maxillary sinuses.

With symmetrical facial structure.

Normal

F. EYES Normal vision of 20/20

With normal vision Normal

G. EARS Hears clearly H. NOSE AND

SINUSESStraight Nasal septum, no discharge present, airway is patent, mucous membranes are pink, no swelling.

No discharge present. Normal

I. MOUTH Lips are moist and pink, no masses, gums are pink and smooth, The tongue is midline and without any hoarseness of voice.

Lips are dry Due to dehydration

J. NECK With normal range of motion, can turn the head against force of

Can turn head against force of the hand and no swelling noted.

Normal

the hand, no swelling.K. THORAX AND

LUNGSThere is no tenderness, chest movement should be symmetric and without lag or impairment. With normal lung sounds

Normal Normal

L. HEART No palpitations, normal PR should be 60- 100 in adult

Without palpitations and the PR is within normal value

Normal

M. BREAST AND AXILLA

Absence of pain, lumps, discharge, or any surgery.

No pain or any discharge

Normal

N. UPPER EXTREMETIES

Extremities should be symmetrical and the skin is warm without any fracture.

Both upper extremities are symmetrical and without fracture

Normal

O. LOWER EXTREMRTIES

Hair covers the legs, the venous pattern is normally visible, both legs are symmetrical and without any swelling.

Normal Normal

P. GROSS MOTOR FUNCTIONS

Gross motor skills involve the large muscles of the body that enable such functions as sitting upright, lifting, and throwing a ball.

Normal Normal

Q. FINE MOTOR TEST

Fine motor skills involve the small muscles of the body that enable such functions as writing, grasping small objects, and fastening clothing.

Normal Normal

R. SENSORY FUNCTION

With normal senses.Can see clearly, can hear accurately, no altered taste, can smell normally.

Can see clearly , hear accurately, smell and feel normally and there is no altered taste

Normal

S. ABDOMEN The contour of the abdomen is usually flat and rounded, the skin surface is smooth, and even with homogenous color

With distention Due to the presence of her disease

and good skin turgor.

XV. Laboratory/Diagnostic Tests:

Hematology Result NORMAL VALUES6/22/13Hemoglobin 122 M- 130-180g/L

F- 120-160g/LHematocrit 0.35 M- 0.40-0.54

F- 0.37-0.47WBC 11.8 5-10x109/L Segmenters 0.53 0.45-0.65Lymphocytes 0.47 0.20-0.35Platelets 258BT 2 mins,10 sec 2-5 minutesCT 5mins,15 sec 5-15 minutes7/6/13Hemoglobin 122 M- 130-180g/L

F- 120-160g/LHematocrit 0.36 M- 0.40-0.54

F- 0.37-0.47WBC 12.3 5-10x109/LSegmenters 0.49 0.45-0.65Lymphocyte 0.51 0.20-0.357/5/13ERC count 3.52 4.05-5.5 x 10 12/1ERC hematocrit 0.30 0.37-0.47Hemoglobin 97.0 120-150g/LLeukocytes 6.29 5-10x10g/LSegmenters 0.70 0.50-0.7Eosinophils 0.02 0-0.05Lymphocytes 0.21 0.10-0.40Platelet count 280 150-450 x 10g/L

Interpretation: The WBC count of the patient is increased that may indicate infection.

Urinalysis Result NORMAL VALUESColor Yellow YellowSpecific Gravity 1.030 1.002-1.030PH 5.0 5-7Sugar Negative NegativeEpithelial Cells Moderate ModerateAmorphous urates Moderate ModerateWBC 3-4 0-2/HPFRBC 1-2 0-2/HPFMucus Threads Moderate Moderate

Clinical Chemistry Result NORMAL VALUES6/27/13Sodium 137.7 137-145 mEq/LPotassium 3.84 3.6-5.0 mEq/LChloride 101.9 98-110 mEq/L

Blood ScreeningType of Component Whole bloodBlood Serial # B-13-1080Blood type ARh PostiveCollection Date 6-24-2013Expiration Date 7-29-2013Amount 500cc

Chest X-rayFindings

Lungs are clearHeart is not enlargedDiaphragms are intact

EvaluationNormal chest

June 23,2013 Abdominal ultrasoundFindings

The abdomen is globular and hazyDistended bowels at the left upper abdomen with thickened interserousal linings and air fluid levelsNo significant gas in the colon and rectosigmoid

EvaluationConsider intestinal obstruction

Plain abdominal ultrasound Findings

The abdomen is globular and hazy.Distended bowels at the upper abdomen, with air-fluid levelsNo significant gas in the lower abdomenNo calcifications

EvaluationConsider intestinal obstruction and ascites May suggest ultrasound of the abdomen

June 28,2013 Abdominal UltrasoundFindings Distended loops of bowels at the left upper abdomen with thickened interserousal linings, air-fluid levels and generalized haziness of the abdomen. Minimal gas and feces in the colon.Evaluation

Consider Partial intestinal obstruction. Consider also bowel wall edema and or intraperitoneal fluid.

Plain abdomen Upright Supine (follow-up)Findings Distended bowels with air fluid levels at the upper abdomen. The abdomen is globular and hazy with thickened interserousal linings No calcification No significant gas in the lower abdomen and rectosigmoid areasEvaluation Intestinal obstruction with bowel wall edema and/or intraperitoneal

fluid. No significant change as compared to the previous x-rays dated 06-23-

2013

COURSE IN THE WARD

06/21/13 Please admit to Female surgical Ward Secure consent for admission TPR every shift and record NPO Dx: CBC,BT

CTBT Urinalysis FBS

IVF of D5LRS 1L for 8hrs Metronidazole 500mg IV every 8 hours Ranitidine 50mg IV every 8 hours For plain abdomen supine upright requested Intake and Output every shift and record Refer accordingly

06/21/13 Please insert NGT Maintain NPO Ketorolac amp IVP every 8 hours Dulcolax suppository: rectum STAT IVF to follow

D5LRS for 8hoursD5NM for 8hoursD5LRS for 8hours

For plain abdominal ultrasound6-26-13 Dulcolax suppository per rectum now- Dr. Galang

For plain abdomen supine upright requested Maintain NPO and NGT Reinsert NGT and connect to beds bottle

6-27-13 Ambulate Serum electrolyte NaKCl

Sched for E/L tom 6-28-13 at 10pm Notify OR and AOD Secure consent please Maintain NPO IVF to follow D5NM for 8 hours

D5LRS for 8 hours Refer

6-29-13 BP 150/100 compress 75mg Please give ketorolac IVP O2 at 2-3 The husband refused oxygen

7-1-13 Dx was explained the need to undergo surgical intervention but was informed by Dr. Panella that surgery will be scheduled on thursday

7-3-13 Schedule for E/L tomorrow 7/4/13 at 10am Secure consent please Notify OR and AOD please Maintain NPO

(+) abdominal pain Give ketorolac amp IVP STAT then every 8 hours for pain

(+) vomiting Metoclopramide(Plasil) amp STAT IVP then TID

7-5-138:40am

Fast drip 300cc of present IVF For repeat CBC

7-5-13 Please transfuse 1 “u” of PNBC Diphenhydramine 1amp to BT

7-10-13 Pull out FC,NGT Maintain NPO Same IVF cycle Refer

7-12-13 Clean to general liquid diet Lower the dosage of ranitidine

7-13-13 May have soft diet On Monday for follow up check up with OPD

7-14-13 DAT in small amount7-16-13 Total removal of sutures

Continue IVF MGH tomorrow Change dressing

PHARMACOLOGIC TREATMENTDate Generic/ Trade

nameDosage/

Frequency/ Route

Classification Indication Contraindication

Side Effects

Nursing Responsibility

7-14-13

Omeprazole (Mefracid)

20mg 1tab OD PO

Belongs to the class of proton pump inhibitor

It is used in the treatment of Duodenal ulcer, Gastric

It is contraindicated in persons with hypersensitivity to the

Possible side effects: breathing difficulty, nausea, fever,

Instruct the patient to take the medication using

ulcer, reflux oesophagitis,Indigestion and stomach discomfort

drug, neonates and during lactation.

weakness, and diarrhea.

the rights of medication administration such as right time, right dose, right route.

6-21-13

Metoclopramide 10mg/2mlTID

It belongs to a group of medicines called ´dopaminergic´ blockers.

Metoclopramide is used short-term to treat heartburn caused by gastroesophageal reflux.

It is also used to treat slow gastric emptying in people with diabetes (also called diabetic gastroparesis), which can cause nausea, vomiting, heartburn, loss of appetite, and a feeling of fullness after meals.

Metoclopramide is contraindicated in pheochromocytoma.

Patients who take antipsychotics are recommended not to take metoclopramide.

Possible Side effects:drowsiness,excessive tiredness,weakness,headache,dizziness,diarrhea, nauseaand vomiting. akathisia, and focal dystonia.

Instruct the patient to take the medication using the rights of medication administration such as right time, right dose, right route.

7-14-13

Cefuroxime 500mg 1tab TID PO

Cefuroxime is a semisynthetic cephalosporin antibiotic(2nd generation), chemically

For respiratory tract infections, meningitis, gonorrhea,

Hypersensitivity to cephalosporins.

Possible side effects:Large doses can cause

Instruct the patient to take the medicati

similar to penicillin

surgical prophylaxis and for susceptible infections

cerebral irritation and convulsions; nausea, vomiting, diarrhea, GI disturbances; erythema multiforme, epidermal necrolysis.

on using the rights of medication administration such as right time, right dose, right route.

Iberet Folic tab OD OP iron and multivitamins; belongs to the class of iron in other combinations.

Prevention & treatment of Fe-deficiency anemia & prevention of folate deficiency.

Thalassemia, sideroblastic anemia, hemochromatosis &hemosiderosis

Possible side effects:GI effects, hyperbilirubinemia, acneform vulgarisdeterioration or acneform exanthema eruption, bright yellow urine discoloration, flushing, dizziness or faintness, peripheral sensory neuropathies, stone formation, crystalluria & oxalosis, black discoloration of stool

Instruct the patient to take the medication using the rights of medication administration such as right time, right dose, right route.

06-20-13

Metronidazole 500mg q8 IV

Antiprotozoal agent-Nitroimidazole group.

Metronidazole is given for treatment of protozoal infections like amoebiasis, giardiasis and trichomonas vaginitis. It is also used in the treatment of anaerobic infection, ulcerative gingivitis, trench mouth, guinea worm infestation.

Metronidazole is contraindicated in blood dyscrasias, hypersensitivity, certain serious neurological diseases, alcohol, severe hepatic failure, pregnancy especially during the first trimester and lactation.

Possible side effects:nausea, diarrhea, and/or metallic taste in the mouth. Intravenous administration is commonly associated with thrombophlebitis. Infrequent adverse effects include: hypersensitivity reactions (rash, itch, flushing, fever), headache, dizziness, vomiting, glossitis, stomatitis, dark urine, and/or paraesthesia.

Instruct the patient to take the medication using the rights of medication administration such as right time, right dose, right route.

6-21-13

Ranitidine 50mg q8 IV

It belongs to a class of drugs called H2 (histamine-2) blockers

Ranitidine tablets are indicated for the treatment of duodenal ulcers and benign gastric ulcers, including that

Ranitidine tablets are contraindicated in patients known to have hypersensitivity to the drug

Possible side effects:Headaches, tiredness, dizziness and mild gastrointestinal disturbance (e.g. diarrhoea,

Instruct the patient to take the medication using the rights of medication administration

associated with non-steroidal anti-inflammatory agents.. This medication is also used to treat certain stomach and throat problems caused by too much acid

constipation and nausea) are among the most frequent complaints

such as right time, right dose, right route.

7-4-13 Ceftriaxone 1GM/IVPSTAT then every 8 hours IVP

Third-generation cephalosporinTherapeutic class: Anti-infective

Bacteremia, Benign gastric, duodenal or NSAID-associated ulceration, Bone and joint infection, Enteric fever, Gonococcal infections, Lower respiratory tract infections, Meningitis, Pneumonia, Pophylaxis of cardiac transplant rejection, Pophylaxis of hepatic transplant rejection, , Skin infections, Soft tissue infections, Surgical prophylaxis,

Documented hypersensitivity; hyperbilirubinemic neonates, particularly those who are premature; neonates 28 d if they receive calcium-containing IV products

Possible side effects:nausea, vomiting, upset stomach,headache, dizziness, overactive reflexes, pain or swelling in your tongue,sweating or

vaginal itching or discharge

Instruct the patient to take the medication using the rights of medication administration such as right time, right dose, right route.

6-29-13

Catapres 75mcg q8 w/n NPOSL

Belongs to the class of imidazoline receptor agonists

indicated in the treatment of hypertension. Catapres (clonidine) tablets may be employed alone or concomitantly with other antihypertensive agents.

Catapres (clonidine) tablets should not be used in patients with known hypersensitivity to clonidine

Possible side effects:drowsiness, dizziness, feeling tired or irritable, cold symptoms such as runny or stuffy nose, sneezing, cough, sore throat, sleep problems (insomnia), nightmare, headache, ear pain, mild fever, feeling hot

Instruct the patient to take the medication using the rights of medication administration such as right time, right dose, right route.

6-22-13

Ketorolac amp q8 IV

Ketorolac is a member of a class of drugs called nonsteroidal antiinflammatory drugs (NSAIDs) that is used for treating inflammation and pain

Short-term management of moderately severe, acute pain requiring opioid-level analgesia.

Aspirin allergy. Peptic ulcer. GI bleed or perforation. As prophylactic analgesic before any major surgery. Treatment of peri-op pain in CABG setting. Advanced renal impairment

Possible side effects:mild heartburn,stomach pain, bloating, gas,dizziness, headache, drowsiness, sweating,ringing in your ears, swelling or rapid weight gain,

Instruct the patient to take the medication using the rights of medication administration such as right time, right dose, right route.

Hypovolemia. Cerebrovascular bleeding. Hemorrhagic diathesis. Incomplete hemostasis. Bleeding disorders or high risk of bleeding. Concomitant probenecid, salicylates, pentoxifylline, other NSAIDs. Epidural or intrathecal inj. Labor & delivery.

fever, sore throat, and headache

Nubain amp for severe pain

Opioid agonist-antagonist

Therapeutic class: Analgesic, adjunct to anesthesia

Nubain is indicated for the relief of moderate to severe pain. Nubain can also be used as a supplement to balanced anesthesia, for preoperative and postoperative analgesia, and for obstetrical analgesia during labor and delivery.

Nubain should not be administered to patients who are hypersensitive to nalbuphine hydrochloride, or to any of the other ingredients in Nubain.

Possible side effects:feeling nervous or restless, depression, strange dreams, bitter taste in your mouth, skin itching or burning, mild rash, blurred vision, slurred speech, or flushing (warmth, redness, or tingly feeling).

Instruct the patient to take the medication using the rights of medication administration such as right time, right dose, right route.

XVII. Nursing Care Plan

Assessment Nsg. Dx Planning Intervention Rationale EvaluationSubjective:“”As verbalized by the patient

Objective: Poor skin

turgor Dry skin Dry lips

Deficient fluid volume related to impaired water absorption as manifested by poor skin turgor

After 8 hours of nursing intervention the patient will show improvement on the objective assessment

Independent: Monitor

vital signs

Assess color and amount of urine

Monitor temperature

Collaborative: Administer

parenteral fluids as ordered by the physician

Fast drip of IVF as ordered by the physician

To evaluate patients current status

To aid in dehydration

To aid in dehydration

After 8 hours of nursing interventions, the patient was able to meet the goal as evidence of improved objective cues

Assessment Nsg. Dx Planning Intervention Rationale EvaluationSubjective:“ sumasakit ang tiyan ko”As verbalized by the patient

Pain scale 5/10As 0 is the lowest and 10 is the highest

Acute pain related to post surgical procedure as manifested by facial grimace and verbal report of acute pain

After 8 hours of nursing intervention the patient will manifest a decrease in the pain scale of 5/10 to a manageable level of 0/10

Independent: Assess

clients pain scale and perception

Encourage verbal report during and

To identify the intensity, onset, duration, and quality of pain

Pain is highly subjective and to identify the effectiveness

After 8 hours of nursing interventions, goals are met as evident of the clients decreased in pain scale from 5/10 to 0/10

With the pain characteristics of moderate pain

Objective: With facial

grimace Verbal

report of acute pain

after the nursing intervention

Monitor vital signs and pain scale

Teach client divertional activities

Advice breathing exercise

Collaborative: Administer

medicine as ordered by the physician

of the intervention

Obtain vital signs, v/s changes during onset of pain, for future comparison of the interventions

To divert clients attention from pain

To allow proper O2 supply on the body. Clients tend to stop breathing during pain

Relieve clients pain using pharmacologic intervention

Assessment Nsg. Dx Planning Intervention Rationale EvaluationSubjective:“ Kaoopera lang sakin”As verbalized by the patient

Objective: Temp -36.3

c Weak in

appearance Clean and

intact abdominal dressing

Risk for infection related to post operative incision

After 8 hours of nursing intervention the patient will be able to identify the risk factors that are present and be free from any signs and symptoms of infection

Independent: Assess signs

and symptoms of infection especially temperature

Emphasize the importance of handwashing technique

Maintain

Fever may indicate infection

It serves as first line defense against infection

Regular wound

After 8 hours of nursing interventions, the patient was able to meet the goal as evidence of able to identify the risk factors that are present and with the absence of the signs and symptoms

aseptic technique when changing dressing/caring wound

Keep area around the wound clean and dry

Collaborative: Administer

antibiotics as ordered by the physician

dressing promotes fast healing and drying of wound

Wet area can be an area for bacteria

Antibiotics will help kill and stop the growth of the bacteria which can cause infection

related to infection

XVIII. Discharge Planning

Medication: The take home meds are as follows:

Iberet Folic tab OD per orem Abound sachet + 100cc cold water 2times for 2 weeks

Instruct the patient to take the medication using the rights of medication administration such as the right time, right dose, right route.

Exercise: Have an adequate rest. Avoid having strenuous activities. Ambulate to improve blood flow and speeds wound healing and it can lead to a quicker

return of bowel function

Treatment: Emphasize adequate rest and sleep pattern. Teach her how and when to take her prescribed medications. Emphasize the importance of frequent hand washing Emphasize the importance of hygiene. Emphasize the importance of wound care

Out- Patient: Have a follow up check- up as scheduled on Monday after discharge.

Diet: Instructed to eat foods that are high in fiber and low in fat. Instructed to eat foods that are rich in proteins. Instructed to eat foods that are rich in vitamin C