Case Presentation and Reports for MSN

8/6/2019 Case Presentation and Reports for MSN

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Katon, Jairus L., RN Page 1

Case Presentation

and

Reports for MSN

a. case presentation




b. report about duty at ER

c. report about the exposure at OPD

d. report about the observation at the Nursing service office

Case Study on Surgical Treatment of

Appendicitis and Appendicial Abscess

Patient Assessment:

Profile:

Name: Mr. Delos Santos

Age: 43 years old

Gender: Male

Birthdate: August 15

Address: Bgy. Cocoro, Cuyo , Palawan

Educational Attainment: Highschool level

Religion: Seventh Day Adventist

Date and Time Admitted: May 3, 2011 / 11:00 am

Attending Physician: Dr. Varona, Dr. Cocjin, Dr. Pacuribot

Diagnosis: Peritonitis / Appedicial Abscess

HEALTH HISTORY.

4 days prior to admission the client experienced severe abdominal RLQ bludgeoning

pain. He complained of tenderness at the RLQ area. Seek medical checkup at Cuyo medical

hospital hence advised to be transferred at Palawan Adventist Hospital. 4 months prior to

admission the client was also admitted at the said hospital due to appendicitis hence

appendectomy was indicated. After surgery last December the patient started to sense

abdominal tenderness at RLQ.

PAST HEALTH HISTORY.

The client only had one history of hospitalization last December 2010 at Palawan

Adventist hospital due to appendicitis. According to him his major health problems aside from

the latter was the infection of chickenpox on November also last year. Common ailments were

experienced by the client such as cough, colds, and influenza; and were treated by over the




counter medication and relief was attained. The client is fully immunized. No reported allergies

on food, drugs and any other substances.

FAMILY HEALTH HISTORY

No occurrence of communicable diseases and heredo- familial disease were reported.

Both mother and father have no history of hypertension, diabetes, liver diseases, kidney

diseases and cancer. All siblings are all alive and apparently well. The client is not an alcoholic

drinker.

FOCUSED PATTERNS OF FUNCTIONING (date of assessment: May 8, 2011, post operative ex-

lap)

SYSTEM CLINICAL EXAM OTHER

SOURCES

A. Respiratory:

(-) hx of respiratory disease

1. RR: 28 cpm, regular with

abdominal splint (pillow) upon

deep breathing.

2. Productive cough noted

whitish secretions.

3. No adventitious lung

sounds noted

Clear chest x-ray results, for

nebulization every 12 hours.

B. Circulatory:

(-) hx of cardiovascular

diseases

(-) chest pains

1. BP: 140/100 mmHg, PR: 80

bpm. No cyanosis, pallor,

edema. 2. Pink nailbeds.

Hgb: 121 g/L

Pltlt: 141x10g/L

C. Food and Fluid Intake

Usual food intakes were rice,vegetable, fruits and fish. No

difficulty in eating.

1. on general liquid diet

2. with D5LR 1 liter plus 10meQs of KCL

3. no solid food for 1 week

D. Elimination

Voids pale yellow urine 5-7

times a day, no urinary

problems noted

1. Able to void via bedside

commode without difficulty,

pale yellow urine, no

bathroom privileges

2. no difficulty upon BM, able

to pass semi solid stools

E. Hygiene

Takes a bath once a day.Brushes teeth regularly.

Changes clothes every day.

1. no bathroom privileges,

able to bath himself at bedwith assistance

2. wound dressing changed

aseptically by the nurse on

duty everyday

F. Activity and Exercise

Usually do household chores

1. Able to sit up on bed

2. Can turn to sides without




every day, work as a

fisherman at Cuyo.

difficulty.

3. Full ROM but with noted

weakness at lower extremities

G. Pain and Discomfort

No pains usually felt.

1. Pain scale of 6/10 at

surgical site.

2. Complains of difficulty of breathing due to abdominal

pain upon exertion.

With Tramadol as PRN meds

MEDICATIONS include:

1. Ceftriaxone

2. Tramadol

3. Metronidazole

4. Paracetamol

5. Omeprazole

6. Iterax

Nursing Care Plans

1. Acute Pain related to surgical wound postoperative explore laparotomy.

2. Ineffective breathing pattern related to site of incisions proximity to the diaphragm.

3. Impaired skin integrity related to tissue damage and incision related to surgical post opwound.

4. Ineffective airway clearance related to retained secretions due to prolonged bed rest and no

bathroom privileges.

5. Risk for infection related to skin opening and presence of abdominal surgical wound.

6. Risk for Imbalance body nutrition related to low calorie and nutrient intake.

Nursing Actions

1. Pain management; pharmacologic and non pharmacologic.

2. Lessen activity or allow to rest to lessen pain episodes.

3. Provide abdominal splint upon deep inhalation and bed mobility.

4. Instruct the client to breath slowly and avoid exertion to avoid pain upon respirations.

5. Provide health teachings on how can he participate on the rapid healing of his wound;

nutrition, wound care, medications and treatments

6. Provide aseptic wound care or as needed as ordered by the physician.

7. Offer back rub and back tapping after nebulizations to help mobilize secretions.

8. Strictly implement prescribed diet.




9. Monitor I and O, vital signs, wound drainage, pain scale and other laboratory values.

10. Monitor wound healing and abdominal status.

11. Regulate IVF as ordered.

12. Offer health teachings about proper post operative exercise, diet, and other tasks.

B. Report on duty at ER

1. Personal experience

Im really happy to be exposed again at the Emergency room of Palawan Adventist

Hospital. Personally for me it is one of the best places to be when your health is at risk. For its

facility is almost complete, friendly and qualified staff, cleanliness and comfort are assured, fasttreatment and God fearing environment. Basically you will be exposed to the ideal ways of

performing nursing interventions with appropriate equipments and materials.

We had 8 patients today. Unfortunately the first one was unlucky because she was

brought by her relatives with weak pulse and respirations and unconscious. Sadly we were not

able to revive the patient after almost an hour of resuscitation. The remaining 7 were just fine.

Abdominal pain, nausea, vomiting, and minor wounds were treated well. We just made

ourselves more familiar to the routine and protocol of ER. Nursing skills were enhanced again

such as intramuscular injection, establishing IV site, CPR, vital signs taking using the latest

equipments and technology and a lot more.

2. Commendations

The staff nurses and nursing aides were so approachable.

Cleanliness and infection control were strictly observed.

Prompt treatment to patients.

Complete set of materials, medicines, and equipments.

Privacy and comfort guaranteed.

3. Suggestions

There should be an adding of 1 or 2 more nursing staff or nursing aides per shift at ER.

Although the patients average is not that high, the nurse may have difficulty in treating high

number of patients in some instances.

The walking distance between ER, laboratory, x-ray rooms, business office and cashier

should be minimized.




C. Report on duty at OPD

1. Personal Experience

It was my first time to be assigned at OPD of PAMC. I have a background working at the

ONP-OPD but the protocols and procedure are different here in PAMC. So I expected it to be a

little difficult at first.

First the assigned staff did a little bit of orientation about OPD. She said we have to

organize our work especially when there are a large number of patients for check up. At first I

had a little difficulty on performing the protocols. Thanks to the friendly staff that guided me all

the way. Skills in communication should be enhanced in this area due to you will entertain

different kinds of people especially they lot of request and inquiries. Communication between

staff nurses is also important.

2. Commendations

Friendly staff.

Easy access to the medical records.

Enough space waiting area of clients.

Close distance to the laboratories, doctors clinic, and x-ray rooms

Proper patient triage

3. Recommendations

Larger lounge or waiting area for the patients

Distance to the ER should be minimized

Ceiling fans for ventilation may not enough if there are lots of patients

D. Report on duty at NSG service

1. Personal Experience

Im really expecting to see a lot of paper works at this area.




2. Commendations

Strict following of policies, rules and regulations

Watchful head nurses and supervisor at all areas

Objective way of evaluating their employees

Assertiveness of head nurses and supervisor

Intact records, manuals, and references

3. Recommendations

Documents

Case Presentation and Reports for MSN