INTRODUCTION

Liver abscess is a pus-filled cyst in the liver. The liver is an organ in the digestive system that assists the digestive process and carries out many other essential functions. These functions include producing bile to help break down food into energy; creating essential substances, such as hormones; cleaning toxins from the blood, including those from medication, alcohol and drugs; and controlling fat storage and cholesterol production and release.

Anyone can get a liver abscess. The condition can be caused by infections spread directly from nearby structures, such as the bile-draining tubes, from the appendix or intestines, or carried in the bloodstream from more distant parts of the body. A liver abscess can also develop as a result of surgery or other trauma to the liver.

The most common type of liver abscess is caused by bacterial or parasitic infection. Bacterial liver abscess is often called pyogenic liver abscess. Microscopic organisms called amebas, which cause the intestinal disorder amebic dysentery, can also cause amebic liver abscess.

When detected in time, liver abscess is usually treatable and often can be cured with a course of antibiotics or a combination of antibiotics and a surgical procedure to drain the abscess. Left untreated, however, a liver abscess can burst and spread the infection, leading to sepsis, a life-threatening bacterial blood infection.

An untreated liver abscess can cause sepsis, a life-threatening blood infection. Seek immediate medical care (call 911) for serious symptoms, such as choking or severe difficulty breathing, which may be combined with high fever (higher than 101 degrees Fahrenheit); change in level of consciousness or alertness, such as passing out or unresponsiveness; or a change in mental status or sudden behavior change, such as confusion, delirium, lethargy, hallucinations and delusions.

Seek prompt medical care if you experience any of the following symptoms, including yellowing of the skin or whites of the eyes (jaundice); abdominal pain (especially in the right upper abdomen); nausea with or without vomiting; clay-colored stools; dark urine; fever or chills; loss of appetite; unexplained weight loss; or weakness.

ASSESSMENT

Patient’s Data Base:

A case of patient B,E , 33 years old, Male, Married, Filipino, Roman Catholic from Luray 2, Toledo Cebu City , weighing 70kgs, 5 feet and 5 inches in height, was admitted for the first time in Vicente Sotto Memorial Medical Center last July 13, 2014 at 10:30am with a chief complaint of abdominal pain and fever; with an admitting diagnosis of hepatic abscess, segment 6 and 7 with the following admitting vital signs of temperature: 38.8°C, Pulse rate: 110bpm, Respiratory rate: 25 cpm, and blood pressure: 140/80 mmHg.

PERSONAL AND SOCIAL HISTORY

1. Lifestyle. Client is not a healthy lifestyle person. He drinks and smoke every day. He is a heavy smoker and a heavy drinker of alcoholic beverages. He consumed 1 packed of cigarette every day and 2-3 bottles of tanduay and generoso.

2. Significant Others/ Important Experiences. His family comes first according to him but if there is one person he runs into when he has problems, it is his wife which is pregnant for 2months, this is the first baby. He loves his wife so dearly. And his wife is his support person

3. Religious Beliefs. Client has a strong belief in God. He is a devoted Roman Catholic and since he cannot go to church every Sunday, he hears the mass in the radio and but not reads the Holy Bible.

4. Environmental Situation. Patient and his family are living together in a house made with concrete materials a few meters away from the street. They have two rooms where all of them sleep at night and a living room that is consist of four chairs. The kitchen and the toilet are located inside the house. They have their own water and electrical supply which they are paying every month to a private supplier in their city. Their garbage is buried at their backyard and they maintain proper drainage system. The surrounding is clean and peaceful with houses not so near from each other. The family has a good relationship with their neighbors. The patient describes them as very helpful, approachable and so kind to them.

5. Substance Abuse. Patient used drugs, like marijuana, his last used was May 2014. He used this drugs for 20 years now.

6. Sexual History. patient is sexually active and had 4 partners in his life.

7. Travel History. Patient has never travelled abroad but he had been around the south of cebu. His last travel was 1 year ago in Naga, Cebu City to visit a relative.

8. Social Activity. Client enjoys being with his friends and family. His usual pastime is drinking together with his friends.

History of Present Illness:

Prior to admission the patient had a fever with 38.5C with pain on his abdomen, and suddenly the patient verbalized that he cannot tolerated the pain because it was not unbearable. He was unable to get up because of the pain in his abdomen with no associated nausea and vomiting, and was continuously feels the pain on his abdominal area. He was then rush to VSMMC for further management and he was diagnosed to have a Hepatic abscess, segment 6 and 7.

History of past illness:

As verbalized by the patient this is his first hospitalization and he has no significant surgical history. His Mother was diagnosed of hypertension. The patients is the 3rd child in the family he has 4 siblings. He works as a construction worker in their hometown. They live in their parents’ house which is extended family, made up of concrete Materials. There are only 8 of them residing in the household. He usually takes his breakfast at 9:00 in the morning, lunch at 12:30 PM, and dinner at 7:00 PM. They’re not used to take in snacks in between meals to economize their expenses. He eats whatever is available for meal. He has no allergies with foods and drugs. Patient usually sleeps 12:00 am. He has no difficulty in urinating. Frequency of urination is approximately 3 times or more a day, yellowish in color and is clear. Her bowel elimination pattern is once a day. He defecates as necessary, usually in the morning. Patient takes a bath once a day. Water source is from MCWD which is stored in gallons. If patient has spare time he plays drinks and smoke with his friends. Patient drinks heavily and smoked every day with 1 packed of cigarette and he used marijuana for 20 years, he usually do this things @ the age of 13 years old.. He has no food preference. Patient has a high blood pressure of 140/90 mmHg. He is not diabetic. His relatives in the maternal side starting with his grandmother and grandfather, both had hypertension and even two of his mother’s siblings. Three of his siblings have hypertension as well. His relatives on the paternal side had diabetes mellitus (paternal grandmother) and asthma (paternal grandfather). His father’s brother has asthma too. That explains why another two of his siblings have asthma.

PHYSICAL ASSESSMENT

I. GENERAL APPEARANCE AND BEHAVIOR

The patient is poor-groomed with unusual body odor noted. He is able to answer the questions cooperatively. He is neither worried nor anxious about his health condition and verbalizes understanding of the treatment and diagnostic test being rendered to him. He is oriented to time, person and the place where he is currently admitted.

II. SKIN AND NAILS

Upon inspection, the patient’s skin is yellowish in color (jaundice noted); there is no presence of palmar pallor. Skin is warm to touch, no pitting edema noted on both hands. Skin turgor returns immediately after pinching. Wound intact noted on the abdominal area. Nails are intact, in flattened angle, Smooth texture in fingernails and toenails noted. There’s dirt in nails noted and acyanotic nails noted. There’s intact epidermis in tissues surrounding nails. Prompt return of pink or usual color generally less than four seconds.

III. HEAD, SCALP AND HAIR

Skull is generally round, with prominences in the frontal and occipital area. No tenderness noted upon palpation. Scalp is moist, no scars noted but with presence of dandruff, no lesions are noted. No tenderness or masses noted upon palpation. Hair is black and is evenly distributed which covers the whole scalp, smooth in texture and is brittle.

IV. FACE, EYEBROWS, EYES AND EYELASHES

Patient’s face is round in shape; no lesion noted and is symmetrical. No involuntary muscle movements and can move facial muscles at will. Eyebrows are symmetrical and in line with each other, it is black in color and is evenly distributed. Eyes are evenly placed and in line with each other, yellowish in color noted, none protruding and equal palpebral fissure, able to follow the object in any direction, pupils constricted in reaction to light. Upon testing for visual acuity, patient able to clearly see and read on near distance but able to read and see clearly on near distance. Eyelashes are evenly distributed. Eyelids closed symmetrically without any discharges.

V. EARS

Auricles have the same color as the facial skin. They are symmetrical and are aligned with the outer canthus of the eyes. Auricles are flexible, firm and no tender. Upon assessment, no redness or purulent discharges were seen on the external canal. Patient can hear in both ears either soft spoken or loud voice.

VI. NECK

The patient’s neck is symmetrical. Upon palpation, lymphnodes in the neck are not swollen. Thyroid gland is not tender and not enlarged. Neck muscles are equal in size. Trachea is positioned in the midline upon palpation.

VII. MOUTH, THROAT, NOSE AND SINUS

Lips are grayish in color, smooth dry without any lesions. Gums are violet to red, with no swelling and bleeding noted. Teeth are yellowish in color, with no dental fillings noted, no malocclusions noted, no evidence of halitosis. Tongue is in midline, pinkish in color, no lesions noted, able to move the tongue freely and with strength. Nose is symmetrical and smooth, the

nasal septum is present, no obstruction to airflow and there are no nasal discharges noted. Frontal and maxillary sinuses are non- tender upon palpation.

VIII. THORAX ANG LUNGS

Respiration 25cpm relaxed and even. Chest expansion is symmetrical. No retraction or bulging of interspaces. No pain or tenderness upon palpation. Vesicular breath sound auscultated over all lung fields. No adventitious sounds present.

IX. BREAST AND AXILLA

Breast sizes are equal and even with the chest wall. The skin is uniform in color to the appearance of the skin of abdomen or back. The skin is smooth and intact. Axilla is smooth without lesion. No enlarged lymphnodes or masses upon palpations.

X. ABDOMEN

The abdomen is unblemished skin and uniform color. The abdomen appears flat and rounded. The abdomen is distended and has audible bowel sound per minute. The abdomen’s movement is symmetric upon respiration. There’s a mass or pain noted upon palpation.

XI. MUSCULOSKELETAL

The both hands are equal in size, even in color, no edema and swelling noted, No hand tremors, no tingling and burning sensation noted. Both legs are even in color. Swelling, tenderness, redness and traction noted on the thigh. With wound dressing on right leg. With mild pain as verbalized by the patient.

XII. GENITALIA

Patient refused to do the assessment. He stated circumcised at the age 9 and that there is no problem with the genitals. There are no lesions as verbalized by the patient.

XIII. GASTROINTESTINAL

The patient claimed that he urinates 3-5 times daily, with moderate amount. Urine color is yellow. He is able to defecate once daily.

CRANIAL NERVE ASSESSMENT

Cranial Nerve 1 (Olfactory. Able to perceive scent on each nostril. Cranial Nerve 2 (Optic). Patient sees clearly. Cranial Nerve 3 (Oculomotor). Eyes move in a smooth, coordinated motion in all directions. Cranial Nerve 4 (Trochlear). Able to control eye movements (interior lateral, medial and superior)

Cranial Nerve 5 (Trigeminal). Temporal and masseter muscles contract bilaterally. Cranial Nerve 6 (Abducens). Eye movements are smooth and coordinated. Cranial Nerve 7 (Facial). Facial movements are smooth and symmetrical. Cranial Nerve 8 (Acoustic). Hears whispered words from 1 to 2 feet on both ears equally. Cannot stand with full balance. Cranial Nerve 9 (Glossopharyngeal). Uvula and soft palate rise bilaterally and symmetrically on phonation. Cranial Nerve 10 (Vagus) Gag reflex is intact. Cranial Nerve 11 (Spinal Accessory). There is symmetric, strong contraction of the trapezius muscle. Cranial Nerve 12 (Hypoglossal): Tongue movement is symmetric and smooth and bilateral strength is apparent.

Other significant findings: hair is wavy; black in color; shoulder length; not extremely oily; evenly distributed; positive for lice; no infestations found. Scalp is dry; with presence of dandruff; white in color; negative for lesions.

NURSING SYSTEMS REVIEW CHART

NGT

INCISION SITE

CATHETER

CVP LINE

D5LR @ 30 GTTS/MIN

HEMATOLOGY

7/19/14 7/20/14 @ 1:05 AM

7/20/14 @10:45 PM

7/22/14 7/25/14

RESULT REFERENCEWBC 14.64 4.8-10.8 15.30 18.64 19.55 17.63 Inc. Due to

infection/presence of pus

HEMOGLOBIN 116 140-180 103 101 99 97 Dec. Due to anemia

HEMATOCRIT 0.33 0.42-0.52 0.28 0.28 0.28 0.29 dec. Due to infection/presence of inflammation

RBC 4.19 4.70-6.10 3.68 3.62 3.62 3.53 Dec. Due to infection/presence of inflammation

RDW 15.30 11-16 15.30 15.30 15.30 25.70 Dec. due infection

NEUTROPHIL 84.80 40-74 88 95 86.30 79.60 Inc. Due to infection/presence of inflammation

LYMPHOCYTE 241.00 19-48 12 02 7.20 8.70 Dec. due infection/presence of pus

Test @ 7/19/14 result referenceamylase 19 decrease 30.0-130lipase 96 normal 70-290

Blood typing 7/19/14

resultBlood type B

Rh Pos (+)

Clinical Microscopy @ 7/20/14

urinalysis ResultColor DrkylwTransparency TurbidSpecific gravity 1.025Ph 6.0Glucose MEG (-)Protein +1RBC 50-100WBC 5-10CAST

Free granular cast >10CrystalsMiscellaneous structuresSquamous E.cell FEWBacteria MOD

COAG @ 7/20/14

PROTOMBINE TIME RESULT REFERENCEProtime 17.9 13.2-16.2% activity 68.2 --INR 1.25 --Control 13.4 --Control % act 120 --Control INR 0.904 --

COAG @ 7/18/14

CREATININE RESULT REFERENCECREATINE 7.14 0.9-1.3SGPT 63.29 0.0-41.0

ABG @ 7/20/14

ABG-POC RESULT REFERENCEPH 7.340PCO2 30.05 7.350-7.400PO2 144.8 35.0-48.0

HCO2 16.5 83.0-108.0BEed 9.4 2.0-3.0TCO2 195 22.0-29.0SO2 99.2 94.0-98.0

CREATININE @ 7/20/14

RESULT REFERENCECREATININE 7.17 0.9-1.3URIC ACID 12.3 3.5-7.3ALBUMIN 2.90 3.5-5.0SODIUM 132.0 135-140POTASSIUM 5.74 3.50-5.30CHLORIDE 103.0 98-107

EPOC-BGEN BLOOD TEST @ 7/20/14

RESULT GASESPH 7.334 LowPCO2 11.0 LowPO2 147.2 HighPH(1) 7.340 LowPCO(1) 30.5 LowPO2(1) 144.8 HighCHCO3 16.5 LowBE(ecf) -9.4 LowCSO2 99.2 HighRESULTS CHEM+NA+ 131 LowK+ 5.1 HighCTCO2 17.5 LowHct 29 LowChgb 9.8 LowBE(B) -8.4 LowRESULT META+Glu 107 HighLac 1.43 High

Gram staining @ 7/22/14

1. Gram stain result FEWEpithelial cells --Predominant organism:

No microorganism seen

CREATININE @ 7/23/14

CREATININE RESULT REFERENCECREATININE 3.58 0.9-1.3SODIUM 136.0 135-148POTASSIUM 4.22 3.50-5.30CHLORIDE 108.5 98-107

ULTRASOUND RESULT: 7/19/14

The liver is enlarged measuring 20.4cm (<15.5cm) taken along the renal axis. There is 11.5x12.8x11.9cm (L x AP) irregular solid focus seen in the right lobe. Color flow study reveals no significant increase vascularity pattern. The rest of the liver parenchyma exhibits homogeneous echo texture and act dilated.

The gallbladder is partially contracted. No intraluminal echoes are demonstrated. The gallbladder thickened measuring 7.6mm (<3mm).

The common duct is not dilated.

The visualized portions of the pancreas are normal in appearance.

ANATOMY AND PHYSIOLOGY

Front View of the LiverThe liver is a large, meaty organ that sits on the right side of the belly. Weighing about 3 pounds, the liver is reddish-brown in color and feels rubbery to the touch. Normally you can't feel the liver, because it's protected by the rib cage.The liver has two large sections, called the right and the left lobes. The gallbladder sits under the liver, along with parts of the pancreas and intestines. The liver and these organs work together to digest, absorb, and process food.The liver's main job is to filter the blood coming from the digestive tract, before passing it to the rest of the body. The liver also detoxifies chemicals and metabolizes drugs. As it does so, the liver secretes bile that ends up back in the intestines. The liver also makes proteins important for blood clotting and other functions. The liver performs many essential functions related to digestion, metabolism, immunity, and the storage of nutrients within the body. These functions make the liver a vital organ without which the tissues of the body would quickly die from lack of energy and nutrients. Fortunately, the liver has an incredible capacity for regeneration of dead or damaged tissues; it is capable of growing as quickly as a cancerous tumor to restore its normal size and function.

Anatomy of the Liver

Gross AnatomyThe liver is a roughly triangular organ that extends across the entire abdominal cavity just inferior to the diaphragm. Most of the liver’s mass is located on the right side of the body where it descends inferiorly toward the right kidney. The liver is made of very soft, pinkish-brown

tissues encapsulated by a connective tissue capsule. This capsule is further covered and reinforced by the peritoneum of the abdominal cavity, which protects the liver and holds it in place within the abdomen.The peritoneum connects the liver in 4 locations: the coronary ligament, the left and right triangular ligaments, and the falciform ligament. These connections are not true ligaments in the anatomical sense; rather, they are condensed regions of peritoneal membrane that support the liver.

The wide coronary ligament connects the central superior portion of the liver to the diaphragm. Located on the lateral borders of the left and right lobes, respectively, the left andright triangular

ligaments connect the superior ends of the liver to the diaphragm. The falciform ligament runs inferiorly from the diaphragm across the anterior edge of the liver to

its inferior border. At the inferior end of the liver, the falciform ligament forms the round ligament (ligamentum teres) of the liver and connects the liver to the umbilicus. The round ligament is a remnant of the umbilical vein that carries blood into the body during fetal development.The liver consists of 4 distinct lobes – the left, right, caudate, and quadrate lobes.

The left and right lobes are the largest lobes and are separated by the falciform ligament. The right lobe is about 5 to 6 times larger than the tapered left lobe.

The small caudate lobe extends from the posterior side of the right lobe and wraps around the inferior vena cava.

The small quadrate lobe is inferior to the caudate lobe and extends from the posterior side of the right lobe and wraps around the gallbladder.

Bile DuctsThe tubes that carry bile through the liver and gallbladder are known as bile ducts and form a branched structure known as the biliary tree. Bile produced by liver cells drains into microscopic canals known as bile canaliculi. The countless bile canaliculi join together into many larger bile ducts found throughout the liver.

These bile ducts next join to form the larger left and right hepatic ducts, which carry bile from the left and right lobes of the liver. Those two hepatic ducts join to form the common hepatic duct that drains all bile away from the liver. The common hepatic duct finally joins with the cystic duct from the gallbladder to form the common bile duct, carrying bile to the duodenum of the small intestine. Most of the bile produced by the liver is pushed back up the cystic duct by peristalsis to arrive in the gallbladder for storage, until it is needed for digestion.

What are the functions of the liver?The liver regulates most chemical levels in the blood and excretes a product called bile. Bile helps to break down fats, preparing them for further digestion and absorption. All of the blood leaving the stomach and intestines passes through the liver. The liver processes this blood and breaks down, balances, and creates nutrients for the body to use. It also metabolized drugs in the blood into forms that are easier for the body to use.  Many vital functions have been identified with the liver. Some of the more well-known functions include the following;

Production of bile, which helps carry away waste and break down fats in the small intestine during digestion

Production of certain proteins for blood plasma Production of cholesterol and special proteins to help carry fats through the body Store and release glucose as needed Processing of hemoglobin for use of its iron content (the liver stores iron) Conversion of harmful ammonia to urea (urea is one of the end products of protein metabolism

that is excreted in the urine) Clearing the blood of drugs and other harmful substances Regulating blood clotting Resisting infections by producing immune factors and removing bacteria from the bloodstream Clearance of bilirubin (if there is a buildup of bilirubin, the skin and eyes turn yellow)

When the liver has broken down harmful substances, they are excreted into the bile or blood. Bile by-products enter the intestine and ultimately leave the body in the feces. Blood by-products are filtered out by the kidneys and leave the body in the form of urine.

PATHOPHYSIOLOGY

ETIOLOGYNON-MODIFIABLE: - AGE

-GENDER

-RACE

MODIFIABLE:

-ALCOHOLIC DRINKER

-SMOKER

-DRUG USER

Klebseilla pnuemoniae and e. coli

DAMAGE LIVER CELLS

DISEASE TISSUE REPLACES NORMAL HEALTHY CELLS

INC. WBC/FATIGUE LIVER INFLAMMATION PAIN/FEVER/LOSS OF APPETITE

ALTERATION IN BLOOD AND LYMPH FLOW

ALTERATION IN LIVER FUNCTIONS

HYPERALDOSTRONISM HYPOALBOMINIMIA DEC. BILE INC. AMMONIA INC.

BILIRUBIN

INC. NA RETENTIO DEC. OSMOTIC PRESSURE EMULSIFICATION OF FATS HEPATIC ENCEPHALOPATHY JAUNDICE

INC. WATER ABSORPTION FLUID SHIFT TO ECFC POOR VIT. K ABSORPTION ALTERATION IN SLLEEP/FOUL BREATH

INC. FLUID VOL. DEMA BLEEDING

DEC. BILE IN GIT AND INC. UROBILIRUNOGEN

PROGNOSIS

MEDICAL – SURGICAL MANAGEMENT

The mortality rate for patients with hepatic abscesses treated with antibiotics and percutaneous drainage is 16%.  A worse prognosis may be expected when there is a delay in diagnosis; multiple organisms cultured from blood; jaundice; hypoalbuminemia; a pleural effusion; or other associated medical diseases.  Complications of pyogenic liver abscess include empyema, pleuropericardial effusion, portal or splenic vein thrombosis, rupture into the pericardium, thoracic and abdominal fistula formation, and sepsis.

Patient E, B’s case is on the Good Prognosis since incision and drainage is already done but he needs to continue the medications given by his physician.

IDEAL ACTUAL

A. DIAGNOSTIC/LABORATORY PROCEDURE

Ultrasound  Abdominal ultrasound is a type of imaging test. It is used to examine organs in the abdomen including the liver, gallbladder, spleen, pancreas, and kidneys. The blood vessels that lead to some of these organs can also be looked at with ultrasound.

Computed tomography (CT−scan) An abdominal CT scan is an imaging method that uses x-rays to create cross-sectional pictures of the belly area. CT stands for computed tomography.

Complete blood count (CBC):  elevated white blood count and high neutrophil level indicates infection

Blood culture A blood culture is a laboratory test to check for bacteria or other microorganisms in a blood sample. Most cultures check for bacteria.

Liver biopsy A liver biopsy is a test that takes a sample of tissue from the liver for examination.

Liver function tests Common tests that are used to see how well the liver is working. This is called liver function. Tests include:

Albumin ALP ALT AST Prothrombin time Serum bilirubin

A. DIAGNOSTIC/LABORATORY PROCEDURE

Ultrasound Done @ July 19, 2014

Not done

CBC done July 19,20,21,22, 2014

Blood culture done @ July 19, 2014

Not done

Done @ July 20, 2014

Urine bilirubin

Blood typingBlood typing is a method to tell what specific type of blood you have. What type you have depends on whether or not there are certain proteins, called antigens, on your red blood cells. This method breaks blood types down into four types:

Type A Type B Type AB Type O

Your blood type (or blood group) depends on the types that are been passed down to you from your parents.

Urinalysis Urinalysis is the physical, chemical, and microscopic examination of urine. It involves a number of tests to detect and measure various compounds that pass through the urine.

B.Medication NSAIDS Effective in relieving pain caused by continuous swelling

Analgesics Relives pain

Antibacterial Inhibits bacterial growth

Anti-inflammatory Prevents inflammation

Anti-anemia Prevents anemia

C. DIET Diet as ToleratedIncreased protein intake and iron

Done @ July 20,2014

Done @ July 20, 2014

B. MEDICATIONSNSAIDS given Ketolorac 30mg IVTT q6hrs X 4 days

Analgesic given Tramadol 50mg IVTT q6hrs x 6 doses Paracetamol 900mg IVTT q6hrsx6doses

Antibacterial given (Quinolones) Lomefloxacin 400mg cap OD Metrodinazole 500mg IVTT q8hrs Piperacillin 2.25mg IVTT q8hrs

Gastric acid suppressant Ranitidine 50 mg q8 hrs Omeprazole 40mg IVTT q24hrsC. DIET NPO @ July 19,20,21, 2014CLEAR LIQUIDS @ July 22,23,2014

D. TREATMENT Moderate high back rest Sit-up on bed Prevent Complication

E. SURGERY Catheter drainage: Caregivers make an

incision (cut) into your abdomen, over your liver. With an ultrasound or CT as guide, a catheter (tube) is inserted in the cut and into the abscess. Draining the abscess may clean out any pus in your abdomen. The incision will be closed with thread or staples. The catheter may be sutured (sewn) to the skin to prevent it from moving. The catheter may need to be flushed with a saline (salt-water) solution once in a while.

Needle aspiration: Caregivers may do a needle aspiration to suck the fluid out of the abscess. With an ultrasound or CT as guide, a needle is put through your skin over your liver and into the abscess. The fluid is removed and sent to the lab for tests.

Surgery: Surgery to open your abdomen may be done if other forms of treatment have failed. It may also be done if the abscess is very large or if there are multiple lesions. Caregivers may do surgery to look for and correct problems inside your abdomen. This may include removing bile duct stones or cleaning pus if the abscess burst.

SOFT DIET @ July 24, 2014DIET AS TOLERATED @ July 25,26,27, 2014

D. TREATMENTAmbulation Deep breathing exercise Monitored Vital signsMonitored I&O

E. SURGERYIncision and drainagelavage

OUTLINE OF NURSING MANAGEMENT

Relieving Pain

Maintain immobilization of affected part by means of bed rest, cast, splint, traction

Evaluate/document reports of pain/discomfort, noting location and characteristics,

including intensity (0–10scale), relieving and aggravating factors.

Perform and supervised active/passive ROM exercises.

Provide alternative comfort measures, e.g., massage, back rub, position changes

Identify diversional activities appropriate for patient age, physical abilities, and

personal preferences.

Administer medication prior to activity as needed for pain

Promoting Physical Mobility Determine presence of complications related to immobility

 Assist with/encourage self-care activities

Assist patient on repositioning of self on regular schedule

Encourage adequate intake of fluids and nutritious foods

 Encourage participation in diversional /recreational activities. Maintain stimulating

environment, e.g., radio, TV, newspapers, and visits from family/friends.

Instruct patient in/assist with active/passive ROM exercises of affected and unaffected

extremities.

Administer medication prior to activity as needed for pain

Preventing Infection

Do frequent hand washing before and after handling the patient.

Teach patient on daily personal hygiene.

Do aseptic technique in assisting wound dressing.

Assess signs and symptoms of infection especially temperature.

Keep area around wound clean and dry.

Administer antibiotic medication as prescribed.

11 KEY AREAS OF RESPONSIBILITIES

1. Safe and Quality Nursing Care

Performed head to toe assessment to know and determine the proper intervention

to be given.

Provided patient safety by ensuring that he has an SO at the bedside.

Checked the doctor’s order before administering a drug and doing procedure to

the patient.

Prepared and gave the medication accurately.

Regulated the patient’s IVF at the prescribed rate.

Recorded the I&O measurement accurately.

2. Management of Resources and Environment

Provided calm and safe environment.

Emphasized to the patient and SO the importance of proper disposal of waste.

Checked the patency of the IV line.

Checked chart regularly for newly prescribed medication.

3. Health Education

Encouraged patient to eat high carbohydrates and Calcium rich foods to promote

healing.

Encouraged to increase his fluid intake.

Stressed the importance of proper hygiene and environmental sanitation.

Educated the patient about the set-up in the OR and stressed out to remove his

jewelries and nail polish prior to OR.

4. Legal Responsibility

Ensured that all consents are signed.

Checked and confirmed information or orders in the doctor’s order.

Documented all the data that was been gathered from the patient.

Documented only the intervention done to the patient.

Maintained patients Confidentiality

5. Ethico- Moral Responsibilities

Provided privacy and confidentiality of all the data gathered from the patient.

Explained the purpose of the assessment and interview and asked her consent or

approval.

Allowed the patient to verbalize her feelings and listen to all the information

given.

Provided the care that addresses to his need in all aspects.

6. Personal and Professional Development

Established rapport and therapeutic relationship to the patient.

Promoted interaction to the family.

Performed ward functions according to professional and protocol of the

area.

Performed nursing procedure in addressing the needs efficiently.

Maintained a respectful attitude towards staff as well as SO.

7. Quality Improvement

Identified patient’s needs for further understanding toward her sickness.

Ensured that the patient follows the correct dietary and medication regimen.

Encouraged the SO and the patient to report unusualities

Checked patient’s record for the laboratory results.

Monitored vital signs every 4hrs. and measured I&O every shift.

8. Research

Utilized research findings about the immediate and effective care to the client’s

condition.

Improved knowledge of patients condition with regards to prevention of

complication

9. Records Management

Maintained accurate and updated documentation of the care done to the patient.

Recorded accurately the vital signs and the Intake and Output.

Ensured that consents were attached in the chart.

Avoid making errors in the chart.

Placed the chart in the right place to avoid misplacement and difficulties in

times of record finding.

10. Communication

Used proper language (Cebuano) in communicating to the patient and SO.

Used therapeutic communication as possible.

Attended to the endorsement and nursing rounds to obtain more information

about the patient.

Promoted interaction with the family.

Gave correct information to avoid misunderstanding.

11. Collaborative and Teamwork

Respected the other role of the health care team.

Informed the C.I for any abnormalities noted and any procedure to be done.

Asked other members of the group about any information they know for the

care and intervention to be given to the patient.

Reference: MSN and Integrated Approach by Luis White and Gena Duncan.

VIII. Discharge Summary

MEDICATIONS >Advised patient to continue taking the prescribed medication on the right dosage, time, and route. >Encourage SO to give medication as prescribed.>Encourage strict adherence to the medication regimen to attain therapeutic effects.>Inform the patient about the different side effects of the medications given and advised patient to report any unusualities.

EXERCISE >Advised patient to avoid strenuous activity. >Advised patient not to lift heavy equipments. >Encourage patient to rest after doing any activity

TREATMENT >Advised patient to put cold/warm compress in his incision site.>Maintain cleanliness and dryness on the wound.>Advised patient to wear clean cloth/t-shirt.

HEALTH TEACHINGS >Advised patient to have proper hygiene.>Instructed patient to report any unusualities in his abdomen. >Give health teaching on the importance of maintaining healthy environment and healthy lifestyle.>Advised patient to have rest, infection prevention such as handwashing.>advised patient to stop smoking, drinking alcoholic beverages and avoid using marijuana.

OUT-PATIENT >Advised patient to have a follow-up check up in the nearest health center. >Encourage SO to refer the patient immediately to the hospital if there are any unexpected health problems that will occur.>Motivate them and highlight the importance of every visit on how it contributes to better health and complete healing.

DIET >Encourage patient to eat healthy and nutritious foods. >Take multivitamins if recommended.

SPIRITUAL >Encourage family to hear masses regularly to strengthen his spiritual life.>Encourage family to pray constantly and surrender all their worries to God especially his present condition to lessen anxiety and to promote presence of mind>Have them join in prayer groups and meeting offered by church or community.

CURRICULUM VITAE

Name : Rabaya, Maria Kaye Camay

Residence: Abellana Street, Suba Pasil, Cebu City

Birthday : July 27, 1993

Birthplace: Hilongos, Leyte

Gender: Female

Religion: Roman Catholic

______________________________________________________________________________

EDUCATIONAL BACKGROUND

Elementary: Bato Central School (2000-2006)

Secondary: Bato School of fisheries (2006-2010)

College: University of the Visayas (2010-2014)

Name of

DrugGeneric andBrand name

Date ordere

d

Classification

DoseFrequen

cyRoute

Mechanism of

Action

SpecificIndicati

on

Side effec

ts

Nursing Interventio

ns

RUG INTERACTION CONTRAINDICATION ADVERSE EFFECTNURSINGCONSIDERATIONGeneric Name:omeprazole

 

Brand Name:PrilosecDrugClassification:

proton pumpinhibitors (PPI)

 Short-term treatmentof activeduodenalulcer; First-linetherapy intreatmentof heartburn or symptomsof gastroesophagealrefluxdisease(GERD); Short-termtreatment ofactive benigngastriculcer; GERD,severeerosiveesophagitis,poorlyresponsivesymptomaticGERD;Long-termtherapy:Treatmentofpathologichypersecretoryconditions (Zollinger-Ellisonsyndrome,multipleadenomas,systemicmastocytosis);Eradication ofH. pyloriWith amoxicillin or metronidazole.Gastric acid-pump inhibitor:Suppresses gastricacid secretion byspecific inhibitionof the hydrogen-potassium ATP asenzyme system atthe secretorysurface of thegastric parietalcells; blocks thefinal step of acidproduction.Omeprazole potentiallycan increase theconcentrations in bloodofdiazepam(Valium),w arfarin (Coumadin),andphenytoin(Dilantin)by decreasing theelimination of thesedrugs by the liver. Theabsorption of certaindrugs may be affectedby stomach acidity.Therefore, omeprazoleas well as other PPIsreduce the absorptionand concentration inbloodofketoconazole(Nizoral)and increase theabsorption andconcentration in bloodofdigoxin(Lanoxin). Thismay reduce the effectiveness ofketoconazole or increase digoxin toxicity Contraindicated withhypersensitivity toomeprazoleor itscomponents;Usecautiously withpregnancy,lactation.Diarrhea, nausea,fatigue,constipation,vomiting,flatulence, acidregurgitation, tasteperversion,arthralgia,myalgia, urticaria,dry mouth,dizziness,headache,paraesthesia,abdominal pain,skin rashes,weakness, back pain, upper respiratoryinfection, cough.

PotentiallyFatal:

Anaphylaxis.

 

Caution patient toswallow capsuleswhole

 — 

not to open,chew, or crush them.Arrange for further evaluation of patientafter 8 weeks oftherapy for gastroreflux disorders; notintended for maintenancetherapy.Administer antacidswith omeprazole, ifneeded.Teaching points: Take the drug beforemeals. Swallow thecapsules whole; donot chew, open, or crush them. This drugwill need to betaken for up to 8wk (short-term therapy)or for a prolongedperiod(> 5 yr in somecases).Have regular medical follow-upvisits.