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I. INTRODUCTION

This is a case about a female patient, E.G.T., who is 34 years old from Nepo, GuaGua, Pampanga. She was admitted at Jose B. Lingad Memorial Regional Hospital

on September 8, 2009 at 7:45 PM, complaining of right upper quadrant pain radiating to back and vomiting. Her final diagnosis was Biliary Ascariasis with 6 weeks age of

gestation.

The roundworm Ascaris Lumbricoides is an extremely common parasite in the intestine. It thrives under conditions of poor sanitation, especially in the tropics, where

warm, humid soil facilitates embryonation of the eggs in the environment. Migration of one or two worms into the biliary tree or also known as biliary ascariasis, is a well

known complication of intestinal ascariasis giving rise to upper abdominal colic, nausea, vomiting and rarely jaundice but massive infestation may rarely occur. In both

cases if not promptly and effectively treated, some secondary complications like cholecystitis, cholangitis, liver abscess, primary duct stone, pancreatitis, benign bile duct

stricture may develop.

The diagnostic tests such as complete blood cell counts, liver function test, serum amylase, chest X-ray, abdominal X-ray and abdominal ultrasound were done in all

patients at the time of admission and repeated when required. The CBC may reveal moderately raised white blood cell count; the liver function tests may reveal elevated

SGPT and SGOT. Abdominal ultrasound, on the other hand, may show dilated biliary duct.

Initial management may include intravenous fluids, IV antibiotics, IV antispasmodics and de-worming. Surgical management of biliary ascariasis may include

Common Bile Duct Exploration, Extraction of ascaris and T-tube choledochostomy.

As of 2007, worldwide prevalence of biliary ascariasis is 15-20%, affecting 7% in male patients and 10% in female patients.

(https://www.researchgate.net/publication/6696326_Biliary_ascariasis). In the Philippines, the prevalence rate is 3%, affecting 1% of the male and 2% of the female

(http://emedicine.medscape.com/article/212510-overview).

The reason why we chose this case is because it captured our interests due to its rare occurrence. And because of that, it posts us a challenge to do research, analyze

the signs and symptoms manifested by the disease that could lead to identification of proper nursing interventions and be familiar with the complications it may bring. We

are also after the knowledge that we may gain by completing this particular case study.

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II. OBJECTIVES

GENERAL:This case study allows the student to gain knowledge about the occurrence Biliary Ascariasis and its management.

SPECIFIC: To study the various types of clinical presentations of biliary ascariasis and their frequency To study the various predisposing factors To study the different types of complications and their frequency To become aware of the various diagnostic tests that will reveal biliary ascariasis To know various treatment options for the management of biliary ascariasis To demonstrate the actual nursing care in the client To provide health teaching to the patient To evaluate the understanding of the patient after the health education

III. PATIENT’S PROFILE

BIOGRAPHIC DATAName: E. G. T.Sex: FemaleAge: 34 years oldCivil Status: SinglePosition in the Family: MotherAddress: Nepo, Guagua, PampangaBirthday: August 19, 1975Birthplace: Guagua, PampangaNationality: FilipinoReligion: Roman CatholicEducational attainment: Grade 4, elementary levelHealth care financing used: noneDate of admission: September 8, 2009Date of discharge: September 15, 2009

Admitting diagnosis: Biliary Ascariasis with + Murphy’s sign and Right Upper Quadrant Pain that radiates to backFinal diagnosis: Biliary Ascariasis with 6 weeks of gestation

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IV. NURSING HEALTH HISTORY

A. CHIEF COMPLAINTAccording to the patient, “I felt severe right upper quadrant abdominal pain radiating to my back. I also vomited.”

B. HISTORY OF PRESENT ILLNESSThree months prior to admission, the patient felt a moderate abdominal pain and sought a consultation at a clinic in Sta.Rita, Guagua, Pampanga wherein she was

diagnosed to have gastritis and was prescribed her to take Zantac. On the following month, still the patient felt on and off moderate abdominal pain and kept on tolerating it thinking it was because of gastritis again. Whenever she feels pain, she immediately stops her work and takes a rest until it subsides. Last September 4, 2009, she experienced vomiting of food and gastric contents and a tolerable abdominal pain. Then, last September 6, 2009, she attended an anniversary celebration of a friend wherein she consumed 500 ml of Red Horse Beer and ate quite a lot of food. Three hours later, she felt severe abdominal pain and was rushed to Diosdado Macapagal Hospital in Sta.Rita, Guagua, Pampanga. It was September 8, 2009 when the doctor of that hospital asked her to have an ultrasound and was diagnosed with biliary ascariasis with 6 weeks gestation. It was also the same day when she was referred to JBL for an emergency operation. She was positive for Murphy’s sign and had a slight jaundice. On September 9, 2009, an emergency operation was performed at 6:50 in the morning. After 3 hours of her operation, while she is still in the recovery room, she vomited ascaris.

C. PAST HISTORYThe patient reported that she had childhood diseases like mumps, chickenpox and measles. The patient had Bacillus Calmette-Guérin (BCG) as evidenced by a

scar on her right deltoid and is not aware of other vaccines that she had received. She completed her tetanus toxoid vaccine in her first pregnancy. As far as the client concerned, she does not have any allergies to any kind of food or insects. She never had any serious injuries. Her first and second time of being hospitalized was last 1997 and 2006, both because of normal spontaneous delivery. Her admission at Sta. Rita was her third time where she stayed there for 2 days. She stayed in the hospitalShe was being hospitalized twice before because of a normal delivery of her children. Confinement at JBL was her 1st time to undergone major surgery. The usual medication she had taken was Zantac which she takes whenever she felt abdominal pain.

D. FAMILY HISTORY OF ILLNESSOn the patient’s paternal side, her grandparents died because of cardiac arrest but she was unable to recall their age of death. Her father died at 60 years of age

because of colon cancer. With regards to the siblings of her father, she is not aware of any diseases they may have. On her maternal side, she was not aware of what causes the death of her grandparents and their age when they died. Her mother is 59 years of age and is asthmatic. She reported that her mother’s sister didn’t have any disease. All of her siblings do not have illness as verbalized by the patient. There are no familial incidences of arthritis, rheumatic fever, tuberculosis.

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GENOGRAM OF THE PATIENT

PATERNAL SIDE MATERNAL SIDE

E.T. A.T. A.G. B.G. 80yearsold 80yearsold 65yearsold 63yearsold

A.T. C.T. S.T. D.T. E.T. H.T. L.T. 67yearsold 65yearsold 60yearsold 56yearsold 54yearsold 59yearsold 56yearsold

E.T. A.T. E.T. A.T. A.T. C.T. A.T. E.T. 36yearsold 35yearsold 34yearsold 31yearsold 29yearsold 27yearsold 25yearsold 23yearsold

LEGEND:

Male

Female

Patient

Deceased

Asthma

Colon Cancer

Cardiac Arrest

Hypertension

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GORDON’S FUNCTIONAL HEALTH PATTERNPrior Hospitalization During Hospitalization

E. HEALTH PERCEPTION AND

HEALTH MANAGEMENT

PATTERN

Patient health is in good health except for periods when she is experiencing abdominal pain. She reported not having any colds or cough in the past month. To keep herself healthy, she eats nutritious foods, eating on time and she does exercise regularly. The client reported that being able to follow the entire doctor’s order and doesn’t believe in folk remedies. She verbalized finding it easy to follow for they have the financial capacity to do so and knew that it will help her to have a good health condition.. She believes that she didn’t need supplements because her diet supplies all the nutrients her body needed. The client was not aware of her actual condition and the etiology of the disease. “I thought that the cause of my abdominal pain was gastritis”, as verbalized by the client. The client is an occasional drinker but does not smoke or use recreational drugs. The last breast examination was done 3 years ago when she had a check up with the ob-gynecologist.

Patient felt weak and lethargic after the surgery but stated that she felt she was regaining her usual state of health and gradually was able to move without assistance. She didn’t have any colds or cough during her stay at the hospital. It is important for her to follow all the orders of the doctor and to eat nutritious foods to regain her strength and have a good health. Most of the time, she thinks of her children especially the baby in her womb, how her condition may affect the baby.

F. NUTRITONAL AND METABOLIC

PATTERN

The patient’s usual food preferences are vegetables, fish and chicken. She said, in the past few weeks her appetite increased. She ate her regular meals with two snacks; she ate bread in the morning and a cup of rice or more in the afternoon. It was really different from her usual diet, she said after eating her breakfast and lunch she didn’t take any snacks. According to her, she prepares and cooks their foods without doing hand washing first. She does not take any supplements and vitamins because she does not want to. She believes that it’s unnecessary to take vitamins because her diet supplies the nutrients that her body needs. Prior to admission the client’s fluid intake was around 1000-1500mL per day. The water they drink came from a poso. The distance of their poso where they drink is less than 20 ft. prior to admission the client was 115 pounds. Her wound heals quickly depending on the wound size. The client has no diet restriction and does not experience loss of appetite after the surgery. Her skin is dry but does not have any lesions other skin problems. The client does not have dentures.

The patient’s typical foods are from the canteen and foods delivered in the ward. After the surgery her daily fluid intake is 600-750L of water. After the surgery, she weighed 110.5 pounds. The doctor ordered nothing per Orem before and after the surgery and instructed diet as tolerated a day after. She was also ordered to have folic acid supplement for her baby’s brain development. There were staple wires present in order to close wound and a cut for the insertion of T-tube.

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SEPT. 5, 2009 SEPT. 4, 2009 SEPT. 3, 2009

7:00 AM 3pcs pandesal100ml of coffee

1:00 PM ½ cup of rice1 small plate of chopseuy150ml of water

7:00 P M ½ cup of rice1 pc fried small galunggong150ml of water

7:00 AM 1 cup of rice2 pcs scrambled egg150ml of water

12:00 PM ½ cup of rice½ fried tilapia150ml of water

7:00PM ½ cup of rice½ fried tilapia100ml of water

7:00 AM 1 cup of rice3 pcs hotdog1 pc sunny-side up egg150ml of water

10:00 AM 1seving of pancit canton3pcs pandesal150ml of water

12:00 PM 1 cup of rice2 pcs fried chicken150ml of water

3:00 PM 1 cup of rice1pc fried chicken150ml of water

7:00 PM 1 cup of rice2 pcs fried porkchop 150ml of water

SEPT. 14, 2009 SEPT. 13, 2009 SEPT. 12, 2009

7:00 AM 1 bowl of lugaw1 pc pandesal150ml coffee

10:00 AM 1 sunkist1 pc apple

12:30 PM 1 cup of rice2 pcs chicken tinola

2:00 PM 1 pc shawarma

7:00 AM 1 bowl of lugaw1 pc pandesal100mL water

10:00 AM 1 pc ice creamV-cut(chips)

12:00 PM 1cup of rice1 kare-kare2 pcs chicken tinola125ml water 4:00 PM 4 pcs crackers150ml Royal

7:00 PM 1 cup of rice2 pcs chicken tinola 10:00 PM 1 cup of noodle soup

7:00 AM 1 bowl of lugaw1 pc pandesal150ml water

12:00 PM 1 cup of rice½ fried tilapia100mL of water

3:00 PM 10 pcs of grapes1 pc apple

7:00 PM 1 cup of rice½ fried tilapia

11:30 PM 1 cup noodles soup

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G. ELIMINATION PATTERN

Patient defecates once a day. Usually, it is color brown, formed and has no strong odor. She doesn’t feel any pain upon defecation. She voids 5-6 times a day. It is usually amber. According to her, she doesn’t feel any pain when voiding and has no difficulty in initiating voiding. She doesn’t also have any problems in controlling it. She doesn’t perspire a lot and has no odor problems.

Patient defecates every other day. The characteristic of her stool are dark brown, formed and has no strong odor. She doesn’t feel pain upon defecation. She voids 5-6 times a day and is usually dark yellow. She doesn’t experience any difficulty in initiating voiding or any pain during voiding. She has no problem in controlling it. She doesn’t perspire a lot and has minimal body odor.

H. ACTIVITY-EXERCISE PATTERN

The patient had sufficient energy in doing all her tasks. She doesn’t easily get tired. She engages in aerobic exercise and does it every day for 30 minutes in the morning at her home. During her spare time, she plays with her children, plays volleyball with her colleagues, races, read newspapers or sleeps.

September 3, 2009

0 Feeding 0 Bathing 0 Toileting 0 Bed mobility0 Dressing 0 Grooming 0 General mobility 0 Cooking

LEVEL 0 - Full self careLEVEL I - Requires use of equipment or deviceL EVEL II - Requires assistance or supervision from another personLEVEL III - Requires assistance or supervision from another person or deviceLEVEL IV – Dependent and does not participate

The patient has no sufficient energy after the surgery. Ambulation and passive ROM activities serve as her form of exercise. Passive ROM exercises were done every morning for 30 minutes for three days after surgery. She has a lot of spare time in the hospital, so most of the time. She reads newspaper, talks with her husband and sleeps.

September 15, 2009

0 Feeding II Bathing II Toileting II Bed mobilityII Dressing II Grooming II General mobility IV Cooking

LEVEL 0 - Full self careLEVEL I - Requires use of equipment or deviceL EVEL II - Requires assistance or supervision from another personLEVEL III - Requires assistance or supervision from another person or deviceLEVEL IV – Dependent and does not participate

I. SLEEP-REST PATTERN

The patient usually sleeps for 10 hours, from 7 pm to 5 am. She doesn’t have any problems in falling asleep. Her sleep is usually continuous. When she wakes up, she feels well rested. She takes naps in the afternoon for 2 hours when she has nothing to do. She watches television programs and reads some reading materials for relaxation.

The patient usually sleeps for 7 hours, from 12 pm to 7 am. She experiences difficulty in falling asleep due to her new environment and limited positions so that she can prevent her T-tube from being dislodged. According to her, “I always have sleepless night since I was admitted in this hospital”. Despite this, she doesn’t take any sleeping pill. She takes naps in the morning and afternoon but it is not continuous because she has to face all her visitors. Taking nap is her activity for her relaxation.

J. SELF-PERCEPTION and SELF-CONCEPT

According to the patient, she is simple. She feels contented about herself and she likes the way she is. She feels angry when her two children fight with each other or when they get naughty. She feels depressed or tearful

The patient is satisfied with herself. She doesn’t think that her surgery will affect her self-esteem a lot. She’s just worried for the condition of her baby and hopes that her baby will be fine and will be properly nourished.

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PATTERN whenever problems come her way and she was not able to solve this. During this time, she seeks the help of her husband.

She gets an emotional support from her husband and other relatives.

K. COGNITIVE-PERCEPTUAL

PATTERN

The patient has no hearing difficulty and has no problem with her eyesight. She doesn’t easily forget things. She does not have any difficulty in learning things. She easily learns when she is interested in a particular topic. Whenever she feels pain, she tolerates it and takes a rest to relieve it.

The patient has no hearing difficulty and has no problem with her eyesight. She doesn’t easily forget things. There is no changes in her memory and does not have any difficulty in learning things. If she feels discomfort or pain, she takes some rest and has a positive attitude that it will subside in just a matter of time.

L. ROLE-RELATIONSHIP

PATTERN

The patient lives with her husband, two children and mother-in-law. She belongs in an extended family. The family handles problem by talking about it. They make sure that they understand each other. Others members of the family become worried about her hospitalization. The family is dependent to her in emotional aspect because she is the one who takes care of the household chores. Sometimes, she has difficulty in handling her children. She belongs in an association of motorcycle riders named Sta. Rita Riders. She also has some close friends and doesn’t feel isolated in the neighborhood where she belongs.

The patient’s family shows emotional support and concern about her condition. Her husband stays with her in the hospital while her mother-in-law temporarily takes care of her two children and some household chores. She is also constantly visited by her friends and colleagues.

M. SEXUALITY-REPRODUCTIVE

PATTERN

The patient and her husband engage in sexual activity. They use natural method for family planning. She had her first menstruation when she was 12 years old. Her menstruation lasts for 3-4 days. She experiences dysmenorrheal during her first day of menstruation. Her last menstrual period was August 7, 2009. Her GT palm score is G3P2 (2002).

The client has no sexual activity.

N. COPING-STRESS TOLERANCE

PATTERN

The patient doesn’t feel tensed a lot of time. Whenever she is stressed, sleeping and watching television programs helps as her form of relaxation rather than alcohol and drugs. Her husband is the most helpful person in talking things over. Her husband is always available whenever she needs him. The death of her father last April 2009, made a big change to her life because she was very close to him. According to her, she was able to cope because life must go on and has to focus with her own family now. Most of the time, her positive attitude towards life helps her to cope with daily stresses of life.

The patient felt anxious about the surgery but her husband was able to help to lessen it. She considered her pregnancy as a big change to her life now. She has to take extra care of herself to protect her baby.

O. VALUE- BELIEF PATTERN

The most important thing to her is her family. Religion also plays an important role in her life. She believes that things are happening because God has a reason. She has faith in Him and that she leaves everything to His will. She also believes that God won’t let her down.

Patient’s faith to God doesn’t change. She always prays for her condition to get better as well as the condition of the baby in her womb.

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V.GROWTH AND DEVELOPMENT

THEORY STAGE NORMAL RESOLUTIONSigmund Freud’s

Psychosocial DevelopmentGenital Stage In this stage, person shakes off old dependencies and learns to

deal maturely with opposite sex.

She should have the desire to marry and raise a family.

In this stage, one requires the taming of aggressive and sexual urges allowing their release in any acceptable manner.

She formed a strong heterosexual relationship with a person outside the family and raised her own family.

Shows dependence with regards to decision-making.

The client shows intimacy with her husband in socially accpetable manner and doesn’t show aggressiveness to satisfy immediately her sexual need.

Erik Erikson’s Theory Adulthood(Generativity vs. Stagnation)

Generativity is the concern for establishing and guiding the next generation. In this stage, one looks beyond oneself and be concerned with others. In this stage shows creativity and productivity.

The patient shows positive resolution by showing care to others especially to her children. By being a volletball player and a motorbike racer, she’s able to show off her skill and talent

Piaget’s Cognitive Theory Formal Operations Phase In this stage, a person is capable of hypothetico-deductive reasonng wherein one can formulate general theory that include all possible factors and also at this stage, one demonstrates propositoinal reasonming where one demonstrates logical thinking.

The patient can think abstractly and can deal not only with real or concrete but with possibilities- potential events or relationships that do not exist but can be imagined.

Kohlberg’s Stages of Moral Development

Postconventional (Social Contract Legalistic Orientation

In this stage, people make an effort to define valid values and principles without regard to ouside authority

The patient judge based on her principles and holding on her opinions and values.

Fowler’s Stages of Spriritual Dvelopment

Paradoxical- Consolidative Aware of truth from variety of viewpointe The cliebt has her own view with regards to spirituality

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VI. ANATOMY AND PHYSIOLOGY

MOUTHThe saliva lubricates and moistens dry food, while chewing distributes the saliva throughout the food mass.The movement of the tongue against the hard palate and the cheeks helps to form a rounded mass, or bolus, of food.

PHARYNXPassageway leading from the mouth and nose to the esophagus and larynx.Permits the passage of swallowed solids and liquids into the esophagus, or gullet, and conducts air to and from the trachea, or windpipe, during respiration.

ESOPHAGUSPasses food from the pharynx to the stomach, is about 25 cm (10 inches) in length; the width varies from 1.5 to 2 cm (about 1 inch).Transport of material through the esophagus takes approximately 10 seconds, when a liquid is swallowed; its transport through the esophagus depends somewhat on the position of the body and the effects of gravity. When the bolus arrives at the junction with the stomach, the lower esophageal sphincter relaxes and the bolus enters the stomach.

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STOMACHReceives ingested food and liquids from the esophagus and retains them for grinding and mixing with gastric juice so that food particles are smaller and more soluble.Main functions of the stomach are to commence the digestion of carbohydrates and proteins, to convert the meal into chyme, and to discharge the chyme into the small intestine periodically as the physical and chemical condition of the mixture is rendered suitable for the next phase of digestion.

SMALL INTESTINEThe small intestine is the principal organ of the digestive tract. The primary functions of the small intestine are mixing, absorbing and transporting of intraluminal contents, production of enzymes and other constituents essential for digestion, and absorption of nutrients.The small intestine, which is 670 to 760 cm (22 to 25 feet) in length and 3 to 4 cm (about 2 inches) in diameter, is the longest part of the digestive tract.The primary purposes of the movements of the small intestine are to provide mixing and transport of intraluminal contents.Three parts are:Duodenum-The duodenum is 23 to 28 cm (9 to 11 inches) long and forms a C-shaped curve that encircles the head of the pancreas.Jejunum-The jejunum forms the upper two-fifths of the rest of the sm.all intestineIleum-“Twisted intestine”.The superior mesenteric artery (a branch of the abdominal aorta) and the superior pancreaticduodenal artery (a branch of the hepatic artery) supply the small intestine with blood.The blood from the intestine is returned by means of the superior mesenteric vein, which, with the splenic vein, forms the portal vein, which drains into the liver.When an inflammatory condition of the small bowel exists, or when irritating substances are present in the intraluminal contents, a peristaltic contraction may travel over a considerable distance of the small intestine; this is called the peristaltic rush.

LARGE INTESTINEThe large intestine, or colon, serves as a reservoir for the liquids emptied into it from the small intestine.It has a much larger diameter than the small intestine (approximately 2.5 cm, or 1 inch, as opposed to 6 cm, or 3 inches, in the large intestine), but at 150 cm (5 feet), it is less than one-quarter the length of the small intestine.The large intestine can be divided into the cecum, ascending colon, transverse colon, descending colon, and sigmoid colon.

LIVERThe liver lies under the lower right rib cage and occupies much of the upper right quadrant of the abdomen, with a portion extending into the upper left quadrant. The organ weighs from 1.2 to 1.6 kg (2.6 to 3.5 pounds) and is somewhat larger in men than in women. This organ plays a major role in metabolism and has a number of functions in the body, including glycogen storage, decomposition of red blood cells, plasma protein synthesis and detoxification.In the first trimester fetus, the liver is the main site of red blood cell productionThe liver breaks down hemoglobin, creating metabolites that are added to bile as pigment (bilirubin and biliverdin)The liver converts ammonia to urea.The liver is a major site of thrombopoietin production. Thrombopoietin is a glycoprotein hormone that regulates the production of platelets by the bone marrow.The liver is divided into two unequal lobes: a large right lobe and a smaller left lobe.

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The major blood vessels enter the liver on its inferior surface in a centrally placed groove called the porta hepatis, which anatomically separates the quadrate and caudate lobes. The liver has two sources of blood supply: fully oxygenated blood from the hepatic artery and partially oxygenated blood from the large portal vein. The major cell of the liver, the Kupffer cell, adheres to the wall of the sinusoid and projects into its lumen, It functions is to engulfs and destroys foreign material or other cells.

GALLBLADDERA pear-shaped organ that lies just below the liver, is attached to the visceral surface of the liver by the cystic duct.The main function of the gall bladder is to store the bile that is secreted by the liver.It concentrates the bile.The gall bladder serves as a holding tank for bile that is used to digest a particularly large or fatty meal.The gallbladder stores about 50 mL (1.7 US fluid ounces / 1.8 Imperial fluid ounces) of bile, which is released when food containing fat enters the digestive tract, stimulating the secretion of cholecystokinin (CCK).The normal adult’s size is 10 x 4 centimeters.

COMMON BILE DUCTTube-like anatomic structure in the human gastrointestinal tract.It is formed by the union of the common hepatic duct and the cystic duct (from the gallbladder)The duct that carries bile from the gallbladder and liver into the duodenum.The common bile duct is a tube that connects the liver, gallbladder, and the pancreas to the small intestine.

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VII. PHYSICAL ASSESSMENT

Name : E.G.T. Date Performed: September 14, 2009Age : 34 years oldSex : FemaleHeight : 5’4”Weight : 112 lbsBMI : 19.22

ASSESSMENT TECHNIQUE NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS

GENERAL APPEARANCE1. Observed body built, height, and weight in relation to patient’s age, lifestyle, and health.

Inspection Proportionate, varies with lifestyle BMI is 19.22, mesomorph Normal

2. Observed patient’s posture and gait, standing, sitting and walking.

Inspection Relaxed, erect posture; coordinated movement

Coordinated movement when walking, sitting and standing

Normal

3. Observed the patient’ overall hygiene and grooming.

Inspection Clean, neat Uncombed hair, her nails are long, her clothes are fixed and straight

Due to self care deficit

4. Noted body and breathe odor in relation to activity level.

Inspection No body or minor body odor relative to work or exercise; no

breath odor.

Minimal body odor, no breath odor noted Due to not taking a bath

5. Observed for signs of distress in posture or facial expression.

Inspection No distress noted. No distress noted Normal

6. Noted obvious signs of health or illness.

Inspection Healthy appearance. No obvious signs of illness Normal

7. Assessed patient’s attitude. Inspection Cooperative The client is able to follow instruction, cooperative

Normal

8. Noted patient’s affect/mood; assessed appropriateness of the patient’s responses.

Inspection Appropriate to situation. Responses of the client are appropriate when client answers the questions

Normal

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9. Listened for quantity of speech, quality and organization.

Inspection Understandable, moderate pace; exhibits thoughts association.

Understandable when speaking Normal

10. Listened for relevance and organization of thoughts.

Inspection Logical sequence; makes sense; has sense of reality.

Responses of the client are appropriate to the questions, her stories are arranged in logical sequence, responses are based on

realities of her experience

Normal

VITAL SIGNS

1. Temperature Inspection 36.5-37.5 C 36.6 C Within the normal range

2. Respiratory Rate Inspection 12-20 CPM 30cpm Above the normal range

3. Pulse Rate Inspection 60-100 BPM 73 bpm Within the normal range

4. Blood pressure. Auscultation 120/80 mmHg 110/70 mmHg Below the normal range

SKIN1. Inspected skin color Inspection Varies from light to deep brown. Light brown Normal2. Inspected uniformity of skin color. Inspection Generally uniform except in areas

exposed to the sun; area of lighter pigmentation.

The skin color is generally uniform, light brown, but the areas that are not exposed

to sun are lighter

Normal

3. Assessed edema, if present (location, color, temperature, shape)

Inspection, palpation No edema. No edema noted Normal

4. Inspected, palpated, and described skin lesions.

Inspection, palpation Freckles, some birthmarks, some flat and raised nevi; no abrasions

or lesions.

Kocher incision on the RUQ, presence of small, flat moles on different parts of the

body, scar on the right deltoid

Due to surgery

5. Palpated skin moisture. Palpation Moisture in skin folds and the axillae.

Presence of moisture in the popliteal, and brachial area

Normal

6. Palpated skin temperature. Palpation Uniform, within normal range. Temperature is bilaterally uniform upon palpation

Normal

7. Noted skin turgor. Inspection Skin springs back to previous state.

Skin on the forehead returns back to normal after being pinched in less than 1

second.

Normal

NAILS

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1. Inspected fingernail plate to determine its curvature and angle.

Inspection Angle of nail plate about 160 degrees.

Convex curvature , no clubbing noted Normal

2. Inspected fingernail and toenail texture.

Inspection Smooth texture Smooth and thick nail Normal

3. Inspected fingernail and toenail bed color.

Inspection Pink ion light-skinned Pinkish Normal

4. Inspected tissues surrounding nails. Inspection Intact epidermis Intact skin, no swelling or redness noted Normal5. Checked capillary refill Inspection Prompt return of usual color

(generally less than 4 sec.)The color of the nail bed returns to light

pink in less than 3 sec. after being pinched

Normal

HAIR1. Inspected evenness of growth over the scalp.

Inspection Evenly distributed hair. Evenly distributed Normal

2. Inspected hair thickness or thinness. Inspection Thick hair Thick hair Normal3. Inspected hair texture and oiliness. Inspection Silky, resilient hair Oily, Straight black hair approximately 12

inches in lengthNormal

4. Noted presence of infections or infestations by parting the hair in several areas, checking behind the ears and along the hairline at the neck.

Inspection No infection No dandruff noted, no swelling or redness noted, scalp is lighter than the skin color

Normal

SKULL AND FACE1. Inspected skull for size, shape, and symmetry.

Inspection Rounded, symmetrical, smooth, skull contour.

Rounded, smooth skull contour Normal

2. Palpated the skull for nodules or masses and depressions.

Palpation Absence of nodules and masses. No masses or nodules noted Normal

3. Inspected the facial features Inspection Symmetric facial features Symmetrical Normal4. Noted symmetry of facial movements Inspection Symmetric facial movements Facial movements are symmetrical Normal

EYES1. Inspected eyebrows for hair distribution and alignment and skin quality and movement.

Inspection Hair evenly distributed Eyebrow is thin, hairs are evenly distributed and directed at the same

direction, no scaling and flakiness of the skin noted

Normal

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2. Inspected eyelashes for evenness of distribution.

Inspection Equally distributed; curled slightly outward

Short eyelashes that are evenly distributed and curled outward

Normal

3. Inspected eyelids for surface characteristics, ability to blink and frequency of blinking.

Inspection Lids close symmetrically. Skin is intact, no discharge noted, bilateral blinking, noted 15-20

involuntary blinks per minute, presence of eye bag

Eye bags are due to disturbed sleep pattern

4. Inspected bulbar conjunctiva for color, texture, and the presence of lesions, inspected sclera

Inspection Transparent; Capillaries sometimes evident

Sclera appears white, yellowish in dark-skinned clients

Conjunctiva is transparentSclera is white in color, no lesions or

nodules noted

Normal

5. Inspected palpebral conjunctiva Inspection Shiny, smooth, and pink or red Smooth, moist, pale red, no lesions or discharge noted

Normal

6. Inspected and palpated the lacrimal gland

Inspection, palpation No edema or tenderness over lacrimal gland

No swelling or tenderness noted upon palpation

Normal

7. Inspected and palpated the lacrimal sac and nasolacrimal duct

Inspection, palpation No edema or tearing No swelling or tenderness noted, no increased tearing noted

Normal

8. Inspected cornea and iris Inspection Transparent, shiny and smooth; iris is flat and symmetry

Cornea is smooth, iris is brown in color Normal

9. Inspected pupils for color, shape and symmetry of size.

Inspection Brown to black in color, round, equal in size

Black pupils which are equal in size, round and with smooth border, and reacts

to light and accommodation

Normal

10. Assessed peripheral vision fields Inspection Client can see object in the periphery while looking straight

ahead

The client can see object in the periphery while looking straight forward

Normal

11.assessed 6 ocular movements to determiner eye alignment and coordination

Inspection Both eyes coordinated, move in unison, in parallel alignment

Eyes are able to follow the penlight, movement is coordinated and move in

unison

Normal

12. Tested visual acuity Inspection Can read newsprint; 20/20 vision on snellen chart

Patient can read newsprint without the aid of eye glasses

Normal

EARS1. Inspected auricles for color Inspection Color same as facial skin Has the same color with facial skin,

symmetrical and aligned with outer canthus of eye

Normal

2. Tested hearing acuity. Inspection Normal voice tones audible, able to hear ticking in both ears.

Client are able to hear on both ears Normal

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3. Watch tick test Inspection Normally the client can identify the sound and at what side it was

heard.

Client are able to hear the watch tick on both ears

Normal

4. Weber’s test Inspection hear sounds equally in both ears (No Lateralization of sound)

Unperformed Due to lack of equipment

5. Rinne’s test Inspection Sound should be heard when tuning fork is placed in front of the ear canal as air conduction< bone conduction by 2:1 (positive rinne test)

Unperformed Due to lack of equipment

NOSE1. Inspected external nose for any deviations in size, shape or color

Inspection Symmetric and straight, no discharge

Symmetric, straight and located in midline, color is the same with the skin of

the face

Normal

2. Inspected the nasal cavities for the presence of redness, swelling, growths and discharge, using the flashlight

Inspection Mucosa pink in color, clear watery discharge, no lesions

No discharge and flaring noted no lesions noted

Normal

3. Inspected the nasal septum between the nasal chambers

Inspection Intact and in midline Nasal septum is intact and in midline Normal

4. Tested patency of both nasal cavities Inspection Air moves freely as the client breathes through the nose

Air is able to move freely as the client breathes through the nose

Normal

5. Lightly palpated for areas of tenderness, masses

Palpation No tenderness, no lesions No tenderness, masses noted upon palpation

Normal

MOUTH1. Inspected outer lips from symmetry, color and texture

Inspection Pink in color, moist, symmetry The mouth is pink to red in color and moist texture

Normal

2. Inspected buccal mucosa for color, moisture, texture and presence of lesions

Inspection Moist, smooth, soft and elastic texture

Mucosa is pink and smooth, moist, no lesions noted

Normal

TEETH1. Inspected for color, number, condition and presence of dentures

Inspection 32 adult teeth, smooth white and shiny tooth enamel

The patient has 32 teeth, yellowish in color, presence of dental caries, and tooth

decay on the 1st molar on the right side

Due to insufficient oral hygiene

GUMS1. Inspected for the color and conditions Inspection Pink gums; moist and no retraction

of gumsMoist and pink gums, no gum problem

notedNormal

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TONGUE/FLOOR OF THE MOUTH1. Inspected for color and texture of the mouth floor and frenulum

Inspection Smooth tongue base with prominent veins

Moist tongue with whitish coating, no lesions and swelling noted

Normal

2. Inspected and palpate, the position, color and texture, movement and base of the tongue

Inspection, palpation Moves freely, no tenderness Tongue is position in center, moist, no tenderness, and moves freely

Normal

3. Palpated for any nodules, lumps or excoriated areas

Palpation Smooth with no palpable nodules Smooth and no nodules or lumps noted Normal

4. Tested for gag reflex Inspection Present Present gag reflex, the client feel nauseated when the posterior tongue was

pressed with tongue depressor

Normal

5. Inspected uvula for position, color and vagus nerve

Inspection Positioned in the mid line, pinkish to red in color, no swelling or lesion, moves upward and backwards when asked to say “ah”

Uvula is located in midline, no swelling and lesion noted. Uvula moves upward and backward when client said “ah”

Normal

NECK1. Located/palpated lymph nodes and note for tenderness.

Palpation Not palpable Lymph nodes are not palpable Normal

2. Inspected and palpated for placement of trachea.

Inspection, palpation Central placement in midline, spaces are equal for both sides

Place in midline with equal space both sides

Normal

3. Inspected symmetry and visible masses.

Inspection Glands ascends during swallowing; not visible

No visible masses, glands ascends when swallowing

Normal

4. Palpated for smoothness and areas of enlargement, masses or nodules.

Palpation Not palpable No areas of enlargement, no nodules and masses palpated

Normal

POSTERIOR THORAX1. Inspected the shape, symmetry, and compared the diameter of anteroposterior thorax to transverse diameter.

Inspection Anteroposterior to transverse diameter is 1:2 ratio, chest

symmetric

The diameter is 1:2 ratio of anteroposterior thorax to transverse

Normal

2. Inspected the spinal alignment. Inspection Spine vertically aligned Spine is in the center and vertically aligned

Normal

3. Palpated for temperature, tenderness, Palpation Uniform temperature, chest wall Slightly warm skin during palpation, no Normal

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masses. intact, no lumps masses and areas of tenderness

tenderness or masses noted

4. Assessed respiratory excursion. Inspection Thumb separation at inspiration Thumbs separated approximately 1 cm during inspiration

Normal

5. Palpated vocal fremitus. Inspection Bilateral symmetry of vocal fremitus

Bilateral symmetry of vocal fremitus Normal

6. Percussed the posterior thorax. Percussion Resonance Resonance sound heard over the area Normal7. Auscultated the posterior thorax. Auscultation No adventitious sound No adventitious sounds during

auscultationNormal

ANTERIOR THORAX1. Inspected breathing patterns. Inspection Quiet rhythmic and effortless

respirationThe patient can breath effortless

respirationNormal

2. Palpated for temperature, tenderness, masses.

Palpation Uniform temperature, no tenderness and masses

Skin temperature is uniform upon palpation

Normal

3. Assessed respiratory excursion. Inspection Thumb separation at inspiration Thumbs separated approximately 1 cm during inspiration

Normal

4. Palpated vocal fremitus. Bilateral symmetry of vocal fremitus

Bilateral symmetry of vocal fremitus Normal

5. Percussed the anterior thorax. Percussion Resonance Resonance sound heard over the area Normal6. Auscultated the trachea. Auscultation Bronchial/tubular breath sounds Tubular breath sounds Normal7. Auscultated the anterior thorax. Auscultation No adventitious sound No adventitious sound heard Normal

CARDIOVASCULAR1. Aortic and pulmonic areas. Auscultation No pulsations No pulsations Normal2. Tricuspid area. Auscultation No pulsations No pulsations Normal3. Apical area. Auscultation Pulsations visible, no lifts or

heavesVisible pulsations Normal

4. Epigastric area. Auscultation Aortic pulsations Aortic pulsations NormalCAROTID ARTERIES

1. Palpated carotid artery with extreme caution.

Palpation Symmetric pulse volume Symmetric pulsation Normal

2. Auscultated the carotid arteries. Auscultation No sounds heard on auscultations No sounds heard during auscultations Normal

JUGULAR VEINS1. Inspected jugular veins. Inspection Veins not visible Veins are not visible Normal

ABDOMEN

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1. Inspected the abdomen for skin integrity.

Inspection Unblemished skin Presence of incision on the RUQ, presence of stretch marks on the right side

of the abdomen

Due to surgery and previous pregnancy

3. Assessed the symmetry of contour while standing at the foot of the bed.

Inspection Symmetrical Symmetric contour Normal

4. Inspected the abdominal movements associated with respirations, peristalsis or aortic pulsations.

Inspection Symmetric movements caused by respiration

Symmetric movements noted during inspiration and expiration

Normal

5. Auscultated the abdomen for bowel sounds, vascular sounds, and peritoneal friction rubs.

Auscultation Audible bowel sounds Audible bowel sounds, no friction rub noted

Normal

6. Performed light palpitation first all four quadrants.

Palpation No tenderness, relaxed abdomen with smooth, consistent measure

Relaxed and soft abdomen, no tenderness during palpation

Normal

MUSCULOSKELETAL SYSTEMUPPER EXTREMITIES1. Muscle strength Inspection Equal strength on both sides Both arms can resist the pressure exerted

by the examinerNormal

2. Muscle tone Palpation Normally firm Firm Normal3. Presence of deformities and varicosities

Inspection No lesion, deformities and tenderness

No lesions and deformities noted Normal

LOWER EXTREMETIES1. Muscle strength Inspection Equal strength on both side Strength exerted by the patient is equal on

both legsNormal

2. Muscle tone Palpation Normally firm Firm Normal3. Presence of deformities and varicosities

Inspection No lesion, deformities and tenderness

No lesions and deformities noted Normal

VIII. REVIEW OF SYSTEM

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Integumentary System Jaundice is due to hyperbilirubinemia. The bile that cannot pass in the duct because of the obstruction backs up to the liver where it is reabsorbed into the blood. It then circulates to the body, staining the skin and sclera.

Gastrointestinal Gallbladder has decreased bile emptying due to an obstruction.

Genitourinary system Elevated serum bilirubin level leads to dark color urine.

SIGNS AND SYMPTOMS WITH RATIONALE:

1. The mature A. lumbricoids reside at the intestine. These cause an irritation on the stomach. Because of this, an impulse will be send towards the spinal cord and to the brain for interpretation. The medulla, which acts as the body’s emetic control system will cause a reverse peristalsis. This peristalsis will cause Abdominal muscle contractions that will increase the intra abdominal pressure that stats vomiting.

2. Pain- Because of the entrance of the A. Lumbricoids in the in the sphincter of Oddi, it will cause an obstruction. The biliary became dilated and atreched that

causes an intense response on its fibers which causes the pain.

3. Jaundice- The bile which is secreted by the liver also functions as vehicle for the bilirubin. Because of the blockage in the biliary duct, there is a barrier for the bile to pass together with the bilirubin. The bilirubin concentration increases, passing from the liver and to the blood. his brought a yellow discoloration in her skin and sclera.

4. + Murphy’s sign- Pain occurs during breathing while a hand is place on the right side of the abdomen under the lower ribs.

5. Abdominal cramping- Due to the pain that originates from the dilated biliary duct, the abdominal muscle also contracts and causes muscle spasm.6. + Bilirubin in the Urine- Elevated indirect bilirubin leaks into the urine which is made possinle by albumin as its carrier.

IX.PATHOPHYSIOLOGY

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Swallowing of larvae from the lungs and return to small bowel

Poor Sanitation and Hygiene

Ingestion of water and food contaminated with A. lumbricoides eggs

Ingested eggs hatch in the duodenum

Penetration of larvae on the wall of the small bowel and move to the blood vessel

Migrate via the portal circulation through the liver

Tropical and Sub- Tropical areas

Circulation of the larvae to the heart and lungs

Larvae lodge in the alveolar capillaries and alveolar walls and mature for ten days

Ascend the bronchial tree into the oropharynx

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Irritation of the stomach lining

A. lumbricous enters the sphincter of oddi and travels the ampulla valtra

Adult A. lumbricous produces for about 200,000 of fertilized ova everyday

Larvae develop into adult worm

Obstruction of the Biliary DuctVagal and enteric nervous system transmit information regarding the state of the GI

Activation of the PNS that increases salivation

Retroperistalsis, starting from the middle of the small intestine

Low intrathoracic pressure with an increase in abdominal pressure as the abdominal muscle contracts

Biliary Ascariasis

Stretch or dilatation of the Biliary Duct

Intense response on fibers of the Biliary tract

Transmission of signals to the spinal cord and to the brain

PAIN

Obstruction of bile within the biliary system

Disrupted metabolism of bilirubin

Impaired bilirubin excreti on

Elevated level of conjugated bilirubin and uconjugated bilirubin

Accumulation of bilirubin in the tissues and blood

+ Murphy’s Sign

Activation of the body’s emetic center (medulla) and the postrema of the brain

Activation of the SNS that increase sweats and heart rate

Propels stomach contents into the esophagus as the lower esophageal sphincter relaxes

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(September 8, 2009)

(September 9, 2009) (September 4, 2009) (September 8, 2009) (September 4, 2009) X. MEDICAL MANAGEMENT

Medical Management

DATE ORDERED

CHANGED GENERAL DESCRIPTION

INDICATIONS/PURPOSES

CLIENT’S RESPONSE

IVF5% Dextrose in Lactated Ringer’s Solution30-31 gtts/min

9/8/09 9/11/09 -hypertonic solution that contains some form of carbohydrate and varying amount of electrolytes

-To deliver the fluid and medicine throughout the body-to maintain fluid and electrolyte

-good skin turgor-moist lips

NURSING RESPONSIBILITIESPRIOR DURING AFTER

1. Explain the procedure to the client.2. Review physician’s order for IV

infusion (type of solution, amount to be administered, rate of flow of infusion, if there are medicine to be added / time to be completed)

1. Assess the client’s response to the IV, rate of IV flow, how much has infused, how much fluid remains to be infused, and condition of the IV insertion site.

2. Inspect for IV tubing patency3. Assess IV site for fluid infiltration,

1. Check for physician’s order for discontinuing IV infusion therapy

2. Assessed for venipuncture site (if there is bleeding, inflammation, phlebitis) for amount of fluid infused

3. Document relevant information, type

VOMITING

Radiates to the back

Causes abdominal contraction

Muscle spasm

Yellowish discoloration of the skin and sclera

when the pharynx is irritated

Leading to gag reflex

Of food and gatric contents

Of AscarisJAUNDICE

Biliubin leaks on the urine

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phlebitis, bleeding.4. In changing the IV container, obtain the

correct solution container, flow rate, amount of solution

5. Use aseptic technique when changing IV solution container, apply new IV tag.

solution used, date and time of discontinuing the infusion

MedicalManagement

DATE ORDERED

CHANGED GENERAL DESCRIPTION

INDICATIONS/PURPOSES

CLIENT’S RESPONSE

Oxygen therapy (2L/min) facial mask

9/9/09 9/9/09 -Administration of oxygen at a concentration greater than that found in the environmental atmosphere.

-Facial mask is used to provide moderate oxygen support and higher concentration of oxygen and humidity

-post anesthesia recovery

-to increase amount of oxygen in the blood ,reduces the extra work of the heart, and decreases shortness of breath

-the patient has no difficulty in breathing noted

NURSING RESPONSIBILITIESPRIOR DURING AFTER

1. Verify the physician’s order for the 1. Assess the patient’s vital sign (ease in 1. Reassess the patient to determine the

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device to be use and flow rate.2. Perform a respiratory assessment to

develop baseline data.3. Place sign “oxyen in use”.4. Inform the significant others about the

safety precautions connected with the use of oxygen .

respiration).2. Assess the patient’s skin for sign of

irritation or tissue necrosis from the facial mask strap.

3. Keep the humidifying jar filled with water at all times.

response to administration of oxygen via facial mask.

2. Document the date, time, procedure performed, method of delivery, and flow rate

3. Record significant deviations from normal, respiratory assessment findings, patient’s response and/or adverse reaction

DRUG STUDY

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Name of drug Date ordered, taken/given Date changed/ D/C

Route of administration, dosage,

frequency

General action, Classification,

Mechanism of Action

Indications/Purpose

Client response to the

medication, actual side effects

Nursing Responsibilities

Generic name: cefuroxime sodium

Date ordered: September 8, 2009

Taken: September 8, 2009

Date changed: September 11, 2009

750mg (vial), TIV, q 8o

500mg tablet, TID, per Orem

Classification: second-generation cephalosporin

General action: treating or preventing bacterial infections by stopping the growth of bacteria

Mechanism of action:Inhibits cell-wall synthesis, promoting osmotic instability; usually bactericidal

Pregnancy Category: B

Reduce incidence of certain post-

operative infection

undergoing surgical

procedures

Client’s response:Patient showed no

signs and symptoms of post-operative infection

No side effect

Prior administration:-verify physician’s order-check expiration date-check for hypersensitivity to cefuroxime or other cephalosporin-assess condition of the patient-explain possible side effectIV-check for any discoloration of the drug-check the IV site (for inflammation, redness or swelling)PO- assess for vomitingDuring administration:-administer as prescribed-administer over 3 to 5 minutesP.O-may take with or without meals-take with full glass of water-do not take a double dose to make up for a missed oneAfter administration:-monitor for adverse effect-report loose stools or diarrhea promptly-document administration of the drug

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Name of drugDate ordered, taken/given

Date changed/ D/C

Route of administration,

dosage, frequency

General action, Classification, Mechanism of Action

Indications/Purpose

Client response to the medication, actual side

effectsNursing Responsibilities

Generic name:acetaminophen paracetamol

Date ordered: September 8, 2009

Date taken:September 8, 2009

Date changed:September 11, 2009

300mg (vial), TIV, q 4O

1 cap TID, PO

Classification: non-opioid analgesic

General action: produce analgesia by blocking pain impulses

Mechanism of action: inhibits synthesis of prostaglandin that may serve as mediators of pain primarily in the CNS or other substances that sensitize pain receptors to stimulation

Pregnancy Category: B

For mild pain

Client’s response:-relieved pain

No side effect

Prior administration:-Verify physician’s order-check for the expiration date-check hypersensitivity to the drug-explain for possible side effect-assess the type, location and intensity of painIV-assess the IV sitePO-assess for vomitingDuring administration:-administer as prescribedIV-slowly administer at least over 3-5 minutesPO-take with food-take with full glass of waterAfter administration:-assess for pain relief-monitor and report for side effects-document administration of the drug

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Name of drugDate ordered, taken/given

Date changed/ D/C

Route of administration,

dosage, frequency

General action, Classification, Mechanism of Action

Indications/Purpose

Client response to the medication,

actual side effectsNursing Responsibilities

Generic name:Ranitidine hydrochloride

Date ordered: September 8, 2009

Date Taken: September 9, 2009

Date changed: September 9, 2009

D/C: September 11, 2009

50 mg (vial), TIV once on call to OR

50mg (vial), IV, q12O

Classification: anti-ulcer drug, histamine H2 antagonist

General action: reducing the amount of acid produces

Mechanism of action: inhibits the action of Histamine at the H2 receptor site located primarily in gastric parietal cells, resulting in inhibition of gastric secretion

Pregnancy Category: B

-To prevent aspiration

pneumonia

-To prevent ulcer

Client’s response:-no dyspnea noted-no abdominal pain noted

No side effect

Prior administration:-verify physician’s order-check expiration date-check for hypersensitivity to drugassess patient condition-assess the IV site-tell patient that it may cause drowsiness or dizziness-assess for abdominal painDuring administration:-administer as prescribed-inject over at least 5 minutesAfter administration:-monitor and report adverse effect- document administration of the drug

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Name of drug

Date ordered, taken/given Date changed/ D/C

Route of administration, dosage, frequency

General action, Classification, Mechanism of Action

Indications/Purpose

Client response to the medication, actual side effects

Nursing Responsibilities

Generic name: Metoclopramide hydrochloride

Date ordered: September 8, 2009Date taken:September 9, 2009D/C:September 9, 2009

1 amp IV once on call to OR

Classification: antiemeticGeneral action: stimulates motility of upper GI tract and increases lower esophageal sphincter toneMechanism of action:Blocks dopamine receptor at the chemoreceptor trigger zone of the CNS

-pregnancy category B

Prevent or reduce nausea and vomiting

Client’s response:

-no side effect

Prior administration:verify physician’s order-check expiration date-check for hypersensitivity to the drug-assess for the IV site-assess for nausea and vomiting, During administration:-administer as prescribed-inject slowly 1-2 minutesAfter administration: -assess for the prevention and relief of nausea and vomiting-assess for cough or dyspnea-report unusual findings or adverse effect-document administration of the drug

Name of drug

Date ordered, taken/given

Date changed/ D/C

Route of administration, dosage, frequency

General action, Classification, Mechanism of

Action

Indications/Purpose

Client response to the

medication, actual side

Nursing Responsibilities

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effects

Generic name:diphenhydramine

Date ordered: September 9, 2009Date taken: September 9, 2009D/C: September 9, 2009

1amp IV stat Classification: anti-histamineGeneral: Prevents histamine-mediated responses, particularly those of the smooth muscle of the bronchial tubes, GI tract, uterus and blood vessels .Mechanism of action: competes with histamine for H1 receptor sites on effector cells.

Pregnancy Category B

- motion sickness(nausea and vomiting)

Client’s response: relief of vomiting

No side effect

Prior administration:-verify physician’s order-check expiration date-make sure IV site is patent-caution client that the medication may cause drowsiness-assess for motion sickness (nausea and vomiting, and abdominal pain)During administration:-administer as prescribed-do not exceed recommended dose-inject atleast 5 minutesAfter administration:-report unusual findings-monitor for adverse effect-document administration of the drug

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Name of drugDate ordered, taken/given

Date changed/ D/C

Route of administration,

dosage, frequency

General action, Classification, Mechanism

of ActionIndications/Purpose

Client response to the medication,

actual side effects

Nursing Responsibilities

Generic name:Multivitamins

Brand name:Rolavit

Date ordered: September 11, 2009Date taken:September 11, 2009

1 cap OD, Per orem Classification:MultivitaminGeneral action: dietary supplement for the treatment and prevention of vitamin deficiencies and necessary for normal growth and development.

- pregnancy category A

-provide vitamins and minerals that are not taken in through the diet

Client’s response:

No side effect

Prior administration:-verify the physician’s order-check expiration date-explain to the client for the side effect-assess if patient has nausea and vomitingDuring administration:-administer as prescribed-take with full glass of waterSwallow on whole-never take more than recommended doseAfter administration:-monitor and report adverse effect-document administration of the drug

Name of drug

Date ordered, taken/given

Date changed/ D/C

Route of administratio

n, dosage, frequency

General action, Classification, Mechanism of

Action

Indications/Purpose

Client response to

the medication, actual side

effects

Nursing Responsibilities

Generic name: dydrogesteroneBrand name:Duphaston

Date ordered: September 8, 2009

Not taken

3 tab initially then 1 tab TID x 3 day, post-op once with diet

Duphaston is an orally active progestogen which acts directly on the uterus, producing a complete secretory endometrium in an estrogen-primed uterus. It is prescribed on a very regular basis during the first trimester of pregnancy. The aim is to mimic the body’s natural progesterone in very early pregnancy

-to prevent miscarriage Prior administration:

-verify physician’s order-check expiration date-assess patient’s condition-explain possible side effects of the drug - This medicine should not be used if you are allergic to one or any of its ingredients.During administration:-administer as prescribed -Swallow the tablets with a glass ofwater-take with or without food-Do not take a double dose to makeup for the one you missedAfter administration: -monitor and report for any side effect -Store in a dry, dark place at temperatures not exceeding 25°C-document administration of the drug

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Name of drug

Date ordered, taken/given Date changed/ D/C

Route of administration, dosage, frequency

General action, Classification, Mechanism of Action

Indications/Purpose

Client response to the medication, actual side effects

Nursing Responsibilities

Generic name:Folic acid (vitamin B9)

Date ordered: September 8, 2009

Not taken

5mg OD until 14 weeks of gestation

Classification: water-soluble vitamin, anti enemicsGeneral action: required for protein synthesis and red blood cell functionMechanism of action: stimulate the production of red blood cells, white blood cells and platelets

Pregnancy Category: A

-given during pregnancy to promote normal fetal development

Prior administration:-verify physician’s order-check expiration date- explain that folic acid may make urine intensely yellow and it is safe for the unborn baby-check plasma folic acid level, hemoglobin,hematocritDuring administration:-Administer as prescribed-take with a full glass of water-skip the missed dose and take the next in regularly scheduled dose After administration: -report unusual findings/ hypersensitivity-advise patient to comply with diet recommendation of health care professional -document administration of drug

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Name of drugDate ordered, taken/given

Date changed/ D/C

Route of administration,

dosage, frequency

General action, Classification,

Mechanism of ActionIndications/Purpose

Client response to the medication,

actual side effectsNursing Responsibilities

Generic name:isoxsuprine

Date ordered:September 8, 2009

Not taken

1 tab TID x 3 day (post -op), PO

Classification: vasodilator

General action: relaxes veins and arteries, which makes them wider and allows blood to pass through them more easily.

Mechanism of action: produces peripheral vasodilation by a direct effect on vascular smooth muscle, primarily within skeletal muscle

Pregnancy Category: C

To prevent miscarriage

Prior administration:-verify physician’s order-check expiration date-tell patient about possible side effect such as drug may cause dizziness- During administration:-administer as prescribed- take each dose with a full glass of water-take with food to avoid stomach upset-don’t take double dose to catch up for the missed dose-After administration:-monitor and report side effects such as chest pain, a pounding heartbeat, skin rash or other side effect-document administration of drug

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XII. DIET

Type of Diet Date startedDate Changed or D/C

General Description

Indications/Purposes Specific foods taken Patient’s Response to Diet

Nothing per

Orem(NPO)

Sept. 8, 2009 to Sept. 10, 2009

NPO refers to total restriction of any food or fluids by mouth.

Rest the 6I tract prior to surgical procedure to decrease peristalsis.

For peri-operative and pre-procedural preparation of patient who will receive anesthesia.

The patient was able to tolerate restriction of any foods and fluids through the mouth.

Diet as Tolerated(DAT)

Sept. 10, 2009Until discharge

DAT is a type of diet that allows the patient to eat whatever foods the patient can chew, swallow, and digest.

For proper intake of essential nutrients and minerals needed by the patient for proper body functioning.

To bring back normal eating habit of the patient as well as her appetite.

To balance nitrogen and its role in healing and recovery process after surgery.

Lugaw Pan de sal Coffee Sunkist Apple Grapes Rice Chicken

(tinola) Shawarma Water Ice cream V-cut chips Kare-kare Sky flakes Royal Cup noodles Kilawin tilapia

The patient ate well The patient ate a lot and no

problem with eating pattern No appetite problem

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NURSING RESPONSIBILITIES

Nothing Per Orem (NPO)

Prior to Administration During Administration After Administration

Explain what is NPO Explain the purpose of NPO Provide health teachings regarding

NPO

Strictly maintain NPO until there’s no Doctor’s order for a change in the type of diet

Assess patient’s condition while NPO is reinforced

Encourage and provide good oral hygiene for comfort and to prevent alteration of the mucous membrane

Evaluate patient’s response to NPO

Diet as Tolerated (DAT)

Explain what is DAT and the purpose of this type of diet

Assess patient’s eating habit and the foods preferred by the patient

Ask what help or assistance is needed by the patient during meal

Assess patient’s metabolic needs Assess whether the patient needs to void or

have a bowel movement before eating Instruct the patient to wash hands before

meal. Provide encouragement and pleasant eating

environment Position the patient in a comfortable

position preferably in sitting position to prevent aspiration.

Observe intake and appetite Provide adequate time for the

patient to eat Assist patient in eating if needed

or ask S.O. to assist patient. Instruct patient adequate intake

of fluids. Make sure the foods are being

served at correct temperature (not too hot or not too cold)

Have the patient wash hands after meal Evaluate patient’s tolerance to meal Remove meal tray and other meal materials

used after eating Provide oral hygiene measures especially oral

hygiene Evaluate patient’s response to food or diet Provide health teachings regarding the

nutrients that can get from foods and the foods needed to be taken.

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XIII. ACTIVITY AND EXERCISE

Type of Exercise General Description Indication and Purposes Client’s ResponsePASSIVE EXERCISE The patient is unable to move

independently and the nurse will move each joint through each range of motion. Movement applied to the body or a body part, by another person or persons (physiotherapy), or via a motion machine. These exercises are carried out by the nurse, without assistance from the patient. Passive exercises will not preserve muscle mass or bone mineralization because there is no voluntary contraction, lengthening of muscle, or tension on bones.

Increase muscle strength

Maintain joint stability Better function of

muscle Promote proper

circulation Promote efficient renal

and gastrointestinal function

-the was able to tolerate the exercise-did not display any signs of performing passive exercise-patient was relieved that even in the hospital she is still able to exercise.

NURSING RESPONSIBILITIESPRIOR:

Assess patients ability to participate in the procedure Ensure that the client understand the reason for doing ROM exercises

Explain the procedure to the clientDURING:

Assess the client if needed Use firm comfortable grip when handling the limbs Move the body parts smoothly, slowly, and rhythmically Avoid moving or forcing a body part beyond the existing range of motion

AFTER Assess vital signs Document significant findings

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NURSING RESPONSIBILITIESPRIOR:

Assess patients ability to tolerance the procedure Assess the patient if she needs assistance performing the procedure Explain the procedure to the client

DURING: Assess the client if needed Encourage client to ambulate independently if she is able, but walk beside the client Be alert for signs of activity intolerance

AFTER Assess vital signs Document significant findings

Diagnostic Laboratory Procedures

Date Ordered and Date result in

Indications or Purposes

Results (1st,2nd , 3rd)

Normal ValuesAnalysis and

Interpretations of the results

AMBULATION To walk about or move from place to place. The act of traveling by foot

- Indicated for patients who require maximum stability and support from an ambulation aid. -To provide physiological benefits such as enhanced venous return, improved renal function, and helps prevent osteoporosis and cardiorespiratory deconditioning.

-The client was able to tolerate the ambulation

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Blood Chemistry‘

Date ordered:

09/08/09

Date result in:

09/08/09

Date ordered:

As part of a routine physical examination.

To help you and your doctor plan changes in your meal plan or lifestyle.

To look for problems, such as a low or high blood glucose level that may be causing a specific symptom.

To follow a specific health condition and check how well a treatment is working.

Before you have surgery.

As a preoperative test to ensure both adequate oxygen

Total Bilirubin (1.85mg/dl)

* Direct Bilirubin (.98 mg/ dl)

*Indirect Bilirubin (.87 mg/ dl)

Alkaline Phosphate (84.0)

SGOT (152.2)

SGPT (219.2)

Total Bilirubin (1.16 mg/ dl )

* Direct Bilirubin (.52mg/ dl)

*Indirect Bilirubin (.64 mg/ dl)

(64-306 IU/L)

(10-4- IU/L)

(0-39 IU/L)

When bilirubin levels are too high, it can cause a condition called jaundice because red blood cells are being broken down too fast for the liver to process. This might happen due to liver disease or bile duct blockage.

Increased direct bilirubin usually means that the biliary (liver secretion) ducts are obstructed.

Normal

Elevated liver enzymes may be a sign of liver disease, hepatotoxicity (liver toxicity) and bile duct disease.

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Complete Blood Count (CBC) 09/08/09

Date result in:

09/08/09

Date ordered:

carrying capacity and homeostasis

To identify persons who may have an infection

To diagnose anemia

To identify acute and chronic illness, bleeding tendencies, and white blood cell disorders such as leukemia

To monitor treatment for anemia and other blood diseases

General health screening to detect renal and metabolic

Hemoglobin (123)

Hematocrit (0.37)

WBC Count (10.4)

Neutrophils (0.80)

Lymphocytes (0.20)

Platelet Count (234)

(115-155) g/l

(0.38-0.48)

(5-10×10*9/L)

(0.45-0.65)

(0.20-0.35)

(150-400×10*9/L)

Normal

Hematocrit is the measurement of the percentage of red blood cells in whole blood and a low hematocrit is referred to as being anemic.

A significant elevation in WBC may indicate infection, inflammatory disease, leukemia and tissue damage such as burns.

Cells involved in fighting infection.Elevation may indicate an acute infection.

Normal

Normal

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Urinalysis09/08/09

Date result in:

09/08/09

diseases

Diagnosis of diseases or disorders of the kidneys or urinary tract

Monitoring of patients with diabetes

Testing for pregnancy

Urine Bile (+)

Color: (Dark Yellow)

Turbid (cloudy)

Amorphous phosphate: heavy

Urine Bile (-)

Straw yellow to amber in color

Transparency: (clear)

Few

If the bile ducts are blocked, direct bilirubin will build up, escape from the liver, and end up in the blood. If the levels are high enough, some of it will appear in the urine.

Unusual urine color may indicate result of certain foods, dyes, supplements or prescription drugs. It can also indicate an infection or serious illness.

Turbid (cloudy) urine may be caused by normal conditions like, precipitation of crystals, mucus, or vaginal discharge. Abnormal causes are the presence of blood cells, yeast, and bacteria.

May due to some medications and food

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Ultrasound Date ordered:

Prior to Hospitalization

Date result in:

09/08/09

Used in screening for disease and to aid in treatment of diseases or conditions.

Has been advocated as a highly sensitive and specific, quick, safe, noninvasive, and relatively inexpensive modality for suspected biliary ascariasis

Sugar: negative

Albumin (Trace)

Specific gravity (1.015)

Pregnancy: (positive)

There are tubular structures w/ echogernic margins and hypochoic center in the left intra hepatic and on line common bile duct.

The liver in normal size. The margins are smooth. The parenchyma is homogenous in echo pattern. There is no mass, calcification nor any other

(-) Sugar

Not trace

Specific gravity (1.10-1.025)

Pregnancy: (negative)

Consider Billiary Ascariasis. Normal liver, gallbladder, pancreas and spleen.

items; also infections.

Normal

Albumin is a carrier of uncojugated bilirubin.

Normal

Normal

Normal

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HBsAg

Prothrombin time

Date ordered:

09/08/09

Date result in:

09/08/09

Date ordered:

09/08/09

Date result in:

09/09/09

Date ordered:

Indicates infectivity. Present in acutely and chronically infectedpersons. Persists indefinitely in chronic carriers. Antigen used in Hepatitis vaccine

Find a cause for abnormal bleeding or bruising.

Check to see if blood-thinning medicine is working

PTT is done to find a cause of abnormal bleeding or bruising.

parenchymal abnormality.

The gallbladder is in size and configuration, no intraluminal calculus or mass. The gallbladder wall is not thickened.

The pancreas and spleen are normal in size and echo texture. No mass or calcification noted.

Nonreactive

Patient (11.3) Control (12.5) Activity (107.1%) INR (0.94)

Nonreactive

seconds 12-15 seconds 70-100% 0.8-1.2

Result revealed that the patient has no hepatitis virus.

A prolonged prothrombin time indicates deficiency of vitamin k due to liver disease.

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Partial Thromboplastin Time

Cholangiogram

09/08/09

Date result in:

09/09/09

Date ordered:

09/11/09

Date result in:

09/13/09

To check for low levels of blood clotting factors.

To check for conditions that cause clotting problems.

To check blood clotting time before a surgery.

To check to see if the dose of anti-clotting medicine is right.

Visualization of the bile ducts to know if there’s a blockages within your common bile duct or hepatic ducts.

To look for remaining stones or stone fragments in the ducts after surgery.

35.4

Scan T-film show stapler at right sub costal area.

Instillation of contrast show good visualization of the hepatobiliary radiation normal caliber and course.

Free flow of contrast to upper GIT noted.

35-45 seconds

A T-Tube Cholangiogram shows the bile ducts when x-ray dye is injected into a T-tube. The biliary tract connects the liver and the gallbladder.

Normal

Normal

NURSING RESPONSIBILITIES

BLOOD CHEMISTRY

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Pretest: -Place patient on NPO for 8 h -Do not drink alcohol before you have this test.Intratest: -Wrap an elastic band around your upper arm to stop the flow of blood. -Clean the needle site with alcohol. -Put the needle into the vein -Remove the band from your arm when enough blood is collected.Post-test: -Apply a gauze pad or cotton ball over the needle site as the needle is removed. -Apply pressure to the site and then a bandage.

COMPLETE BLOOD COUNT (CBC)

Pretest: -obtain syringe, tourniquet, vial with appropriate anticoagulantIntratest: -Cubital vein commonly used for venipuncture Post-test: -direct pressure and observe for bleeding, label vial

URINALYSIS

Pretest: -give clean vial and instruct to void directly into the specimen bottleIntratest: -Allow a 10 ml collectionPost-test: -prompt delivery to laboratory

ULTRASOUND

Pre-test: -Wear a gown, removed all kinds of jewelry Intratest: - A clear gel will be placed on the skin over the area to be examined.

- The transducer will be pressed against the skin and moved around over the area being studied. Post Test: -Wipe off the gel -Resume normal activities within a few hours

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HBsAg

Pre-test: -Explain the procedure to the patient -Tell the patient that no fasting is requiredIntratest: -Apply pressure or a pressure dressing to the venipuncture site -Handle the specimen as if it were capable of transmitting hepatitisPost Test:-Immediately discard the needle in the appropriate receptacle -Send the specimen to the laboratory

PROTHROMBIN TIME

Pretest: -Check if the patient is taking any medications that may affect the results Intrtatest: -Cleans the skin surface with antiseptic solution - Elastic band (tourniquet) is placed around the upper armPost-test: -Routine care of the area around the puncture mark -Pressure is applied for a few seconds and the wound is covered with a bandage

PARTIAL TROMBOPLASTIN TIME

Pretest: -Check if the patient is taking any medications that may affect the results -If the patient is on heparin therapy, the blood sample is drawn one hour before the next dose of heparin

Intrtatest: -Cleans the skin surface with antiseptic solution - Elastic band (tourniquet) is placed around the upper armPost-test: -Routine care of the puncture site. -Watched for signs of spontaneous bleeding -Patient should not be left alone until bleeding has stopped

-Advise patient to watch for bleeding gums, bruising easily or other signs of clotting problems

CHOLANGIOGRAM

Pretest: -Patient’s identification (3 Cs- correct patient. correct side, correct procedure)

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-Patient should be wearing a hospital gown -Consent form -No diet restriction -Collect relevant previous imaging -Prophylactic dose of brood spectrum antibiotic (immunosupressed patient)

-Clamp the T-tube Intratest: -Contrast medium will be given slowly under fluoroscopy. - You will be asked to hold your breath as the x-rays are taken.

-Dressing will be applied to the area if necessary upon completion of the exam. Post-test: -Patient can eat and drink normally -Warn patient to advice of any itching or rash post procedure -Patient should remain in hospital for observation for at least 24 hours

XV. SURGICAL MANAGEMENT

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Date ordered:September 8, 2009

Date performed: September 9, 2009

Description:Cholecystectomy is the surgical removal of the gallbladder. CBDE (Common Bile Duct Exploration) is a procedure used to see if a stone or some obstruction is

blocking the flow of bile from your liver and gallbladder to your intestine. It is usually done during the removal of the gallbladder. T-tube insertion is a process wherein a narrow flexible tube in the form of a T is used for drainage especially of the common bile duct. The main reasons for using T-tube drainage after open common bile duct exploration are post-operative drainage of the bile duct and visualization of the bile duct.

Materials used: Sterile drape

Mosquito

Kelly curves

Allis

Babcock

Needle holder

Tissue forcep

Thumb forcep

Kidney basin

Towel clips

Straight clamp

Mixter

French 16 T-tube catheter

Drainage bag

Vicryl-0

Chromic 2-0

Vicryl 4-0

Sterile dressing

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Procedure:1. Patient is placed in supine position under SAB

2. Asepsis- Antisepsis technique done3. Sterile drapes placed

4. Right Kocher incision done on the skin carried and down to the subcutaneous tissue

5. Rectus sheath cut and opened6. Rectus abdominal muscle divided with electrocautery

7. Posterior rectus sheath picked up and cut8. Peritoneum identified cut and entered

9. Pass a hand over the right lobe of the liver and pulled it down10. Gallbladder is grasp with forceps and retracted laterally

11. The peritoneal reflection of the ampulla identified and incised 12. Common bile duct identified

13. Removal of the gallbladder done14. CBD opened using blade 12 about 1 cm, parallel to the long axis of the CBD

15. Exploration of the CBD done16. Extraction of ascaris done

17. Patency of the duct and papilla identified

18. A catheter inserted and flush the ducts with warm saline, first towards the liver then downward towards the duodenum

19. A French 16 T-tube catheter, with shortened arm and wedge is excised opposite the main stem, is inserted through the CBD incision

20. Opening in the CBD about the catheter is closed securely 21. Test for any leak by infusing warm saline through the T-tube

22. Drain is placed23. Hemostasis done

24. Peritoneal toilette done25. Layer by layer closure

25.1 Peritoneum closed by continuos interlocking sutures using Vicryl-0

25.2 Fascia closed by continous interlocking sutures using Vicryl-0

25.3 Subcutaneous  closed by Inverted T sutures using Chromic 2-0

25.4 Skin closed subcuticularly using vicryl 4-0.26. Dry Sterile Dressing applied

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Pre-operative nursing responsibilities Intra-operative nursing responsibilities Post-operative nursing responsibilities

1. Secure consent acknowledging that the patient understands the procedure, risks and that she will be receiving anesthesia and other possible medications.

2. Obtain health history and perform physical examination to establish vital signs and database for future comparison.

3. Explore any fears with patient and help reduce the anxiety.

4. Teach patient about deep breathing exercises.

5. Maintain NPO status the night before the surgery.

6. Secure laboratory procedures.7. An intravenous (IV) is started for fluids

and medication.

1. Assist patient with proper position for surgery.

2. Monitor vital signs.3. Strictly follow the principles of surgical

asepsis.4. Scrub nurse should count all instruments

and sharps before and after the procedure.

5. Scrub nurse should hand the surgeon the correct instrument.

1. Monitor vital signs closely.2. Keep NPO status until the return of the gag reflex

or until an order is made.3. Place patient flat on bed.4. Regulate IV fluids.5. Assess output from wound drainage.6. Assess patient's level of pain.7. Monitor for any complications like bleeding.8. Administer medications as prescribed.9. Administer oxygen inhalation as ordered.10. Perform daily wound care.11. Encourage patient to take deep breaths to prevent

lung complications.12. Encourage frequent position changes to stimulate

circulation.

Patient’s response

1. Patient's bed mobility is affected because of the incision and the T-tube.

2. Patient's appetite is good.3. Patient's pain in the upper right

quadrant was eliminated.

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XVI. NURSING CARE PLAN

PRIORITIZATION TABLE

Priority Number Nursing Diagnosis Related Factor1 Impaired Skin integrity Related to placement of T-tube.

2 Sleep pattern disturbance Related to environmental changes evidenced by complaints of falling asleep.

3 Knowledge deficit Related to information misinterpretation about the cause of the disease.

4 Potential for infection Related to invasive procedure.

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Assessment Nursing Diagnosis

Scientific Explanation of

the Problem

Planning Interventions Rationale Evaluation

Subjective:

Objective:-redness

-disruption of the skin surface on the RUQ of the abdomen

-invasion of body structure

Impaired Skin integrity related to placement of T-tube.

Altered epidermis or dermis.

There is mechanical trauma and disruption of the first line of defense to the skin related to the operation. The nerve endings are irritated and sends signal to the brain. Which release bradykinin, which causes vascularization and redness to the injury site. (pg. 71 Elaine Marieb)

After 5-6 hours of nursing intervention the patient demonstrates behaviors to promote healing and prevent skin breakdown.

-check the T tube and incision drains make sure they are free flowing.

-observe the color and character of the drainage.

-anchor drainage tube, allowing sufficient tubing to permit free turning, and avoid kinks and twists.

-place patient in low or semi-Fowlers position.

-change dressing as often as necessary.

-instructed patient to increase food intake rich in protein

-emphasized to the client the importance of proper hand washing and hygiene.

-T tube may remain in CBD for 7-10 days to remove retained drainage. Incision sites drains are used to remove any accumulated fluid and bile. Correct positioning prevents backup of the bile.

-may contain blood, normally changing greenish brown (bile color) after the first several hours.

-avoids dislodging tube and occlusion of the lumen.

-facilitates drainage of bile.

-keeps the skin around the incision clean and provides a barrier to protect skin from excoriation.

-these types of food help in tissue healing

-handwashing helps prevents the spread of disease.

The patient demonstrated behaviors to promote healing and prevent skin breakdown.

GOAL MET

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Assessment Nursing Diagnosis

Scientific Explanation of the

Problem

Planning Interventions Rationale Evaluation

Subjective:The client reported of having sleepless nights since she was admitted in the hospital

Objective:-restlessness

-presence of eyebags

Sleep pattern disturbance related to environmental changes

Sleeping difficulty can involve difficulty falling asleep when you first go to bed at night, waking up too early in the morning, and waking up often during the night.(http://www.britannica.com/)

-After 1-2 days of nursing interventions the patient will report improvement in sleep and rest pattern.

-determine normal sleep habits and changes that are occurring

-establish sleep routine suitable to old pattern and new environment.

-encourage some light physical activity during the day. Make sure the client stops activity several hours before bedtime.

-instruct relaxation methods.

-Encourage position of comfort if needed assist in turning

-assesses need and identifies appropriate nursing interventions

-when new routine contains as many aspects of old habits as possible, stress and related anxiety may be reduced

-daytime activity can help patient expend energy and be ready for nighttime sleep.

-helps to induce sleep

-repositioning alters areas of pressure and promotes rest.

The patient reported some improvement in sleep and rest pattern.

GOAL: PARTIALLY MET

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Assessment Nursing Diagnosis

Scientific Explanation of

the Problem

Planning Interventions Rationale Evaluation

Subjective: The client reported of not being aware that improper hygiene can cause the disease.

Objective:-lack of information about the cause disease

Knowledge deficit related to lack of information about the cause of the disease

The absence of cognitive information related to the cause of the disease.

The patient was not aware what the cause of the disease; therefore she is unable to take measures to prevent the disease.

After 2-3 hours of nursing intervention the patient will verbalize understanding of the disease process and will initiate necessary lifestyle changes.

- Review the disease process and future expectations.

-review individual risk factors and mode of transmission and portal entry of infections

-discuss need for good nutritional intake and balanced diet

-encourage adequate rest periods with scheduled activities

-review necessity of personal hygiene and environmental cleanliness

-provides knowledge base on which patient can make informed choices

-being aware of how infection is transmitted provides opportunity to plan for protective measures.

-necessary for optimal healing and general well-being.

-prevents fatigue, conserves energy and promote healing

-helps to control environmental exposure by diminishing the number of pathogens present.

The patient verbalized the understanding of the disease process and will initiate necessary lifestyle changes.

GOAL MET

Assessment Nursing Diagnosis

Scientific Explanation of

the Problem

Planning Interventions Rationale Evaluation

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Subjective:

Objective:-broken skin

-invasive procedure

-insufficient knowledge to avoid exposure to pathogens

-redness

Risk for infection related to invasive procedure.

At increased risk for being invaded by pathogenic organisms due to the disruption of the first line of defense.

There is a disruption of the first line of defense, can be a portal of entry to microorganisms. Presence of microorganisms can cause infection.(www.Wikipedia.com)

After 2-3 hours of nursing interventions the client identifies individual risk factors and interventions to reduce risk for infection.

-assess wound site

-Adhere to hospital infection control, sterilization and aseptic policies/procedures.

-review laboratory studies for possibility of systemic infections

-examine skin breaks or ongoing infection.

-maintain dependent gravity drainage of T tubes and parenteral sites.

-provide sterile dressing

-the site indicates whether there is infection.

-Established mechanisms to prevent infection

-increased WBC may indicate ongoing infection.

-disruptions of skin integrity at or near the operative site are sources of contamination to the wound.

-prevents stasis and reflux of body fluids.

-prevents environmental contamination of fresh wound.

The client identified individual risk factors and interventions to reduce risk for infection.

GOAL MET

XVII. HEALTH TEACHING

Health teaching Rationale

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Provide clean environment. To prevent infection

Advice to avoid high fat diet to lessen the bile secretion

To lessen the bile duct secretion

Instruct to have adequate rest and sleep To facilitate early recovery from surgeryImprove sanitation and hygiene like proper hand washing particularly after using bathroom and before eating

Improper hand washing may increase the risk of ingestion of ova.

Instruct patient that the dressing around the T- tube should be changed at least once daily, and more often if it becomes moist

Moist materials harbor microorganisms that may cause further infection

Advice patient to avoid peppery and spicy foods

they induce increased worm migration

Instruct to eat nutritious food like fruits and vegetables, and drink adequate and clean fluids

To promote wound healing and to prevent recurrence of ingestion of ascaris

Instruct the patient to inform a health care provider if she will experience dark urine, jaundiced color of eyes/skin, clay-colored stools, excessive stools, or recurrent heartburn, bloating.

To provide initial treatment and reduce worsening of the condition

Advice the patient to boil the water used for drinking and cooking.

Boiling helps to kill the disease causing-microorganisms.

XVIII. DISCHARGE PLANNING

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M – MEDICATIONInstruct the patient the proper way of taking her medicines by explaining to the patient the amount, frequency, and the time to take the medicine. For example,

Rolavit 1 cap, once a day, 750mg of cefuroxime should take every 8 hours, and folic acid 5mg OD until 14 weeks of gestation. E – ENVIRONMENT/EXERCISE

For environment, instruct the patient to provide a clean environment to her, such as clean or filtered water, and to have clean and proper preparation of foods.Inform the patient that she may resume her normal activites after 4-6 weeks. Encourage the patient to do some exercise like walking. And avoid lifting of heavy

materials.

T – TREATMENTInstruct the patient to continue to take the prescribed medications.

H – HYGIENEInstruct the patient to perform proper hand washing particularly before eating, take a bath every day, keep her fingernail clean and short and always wear a sleeper.

O – OUT PATIENTInform the patient to consult a doctor if she experiences any of this: continues nausea or vomiting, redness, swelling, bleeding or drainage at the incision,

temperature above 101 degrees, increase abdominal pain, severe shoulder pain, lasting more than 3 days. Advice patient to return to the hospital after 2 weeks for the removal of the T-tube.

D – DIETInform the patient that she is able to resume a normal diet after one week of the surgery. Advice patient to avoid peppery and spicy foods because they induce

increased worm migration. And also avoid high fat diet to lessen the bile secretions.

S – SEXUALITY/SPIRITUAL Advice the patient to pray. Ask the client whether she feels that her surgery will affect her sex life. Advice significant others to give emotional support to the patient.

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XIX. CONCLUSION

Biliary Ascariasis presents symptoms like abdominal pain, nausea, vomiting and rarely jaundice. By means of different diagnostics tests, presence of worm in the biliary

tract can be detected. Early surgical intervention is advisable in patients to prevent further complications like cholecystisis, cholangitis, liver abscess, primary duct stone,

pancreatitis, benign bile duct stricture. But then the solution to the problem of biliary ascariasis does not lie in surgical intervention but prevention by means of providing

safe drinking water, proper disposal of night soil, good hygiene and de-worming of all children in endemic areas at regular intervals. We suggest that there should be a

national program for eradication of worms in endemic areas.

XX. BIBLIOGRAPHY

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1. Marieb Elaine, (2007) Essential of Anatomy and Physiology

2. Carol Taylor, 5th edition Fundamentals of Nursing., The Art and Science of Nursing Care

3. Barbarra Kozier, 7th edition Fundamentals of Nursing.

4. Ellie Whitney, 10th edition, understanding nutrition

5. Huether, Sue E. and Kathryn L McCane 2nd ed. Understanding Pathophysiology

6. Smeltzer, Susanne C. Breanda G. Care, Janice L. Hinkle and Cheener Kerry A. 11th ed. Textbook of Medical Surgical Nursing

7. Principles of pathophysiology and emergency medical care, Jeffrey W. Myers, Marianne Neighbors, Ruth Tannehill-Jones

8. http://www.medscape.com/viewarticle/448329_3

9. http://www.DrugGuide.com\

10. http://www.yahoo.com\

11. http://www.google.com\

12. http://www.cochrane.org/reviews/en/ab005640.html

13. http://www.britannica.com/

14. http://www.wikipedia.com

15. http://emedicine.medscape.com/