INTRODUCTION

Liver Cirrhosis is derived from Greek word kirrhos, meaning "tawny" (the

orange-yellow colour of the diseased liver). It is a consequence of chronic liver disease

characterized by replacement of liver tissue by fibrous scar tissue as well as regenerative

nodules (lumps that occur as a result of a process in which damaged tissue is

regenerated), leading to progressive loss of liver function. Cirrhosis is most commonly

caused by alcoholism, hepatitis B and C and fatty liver disease but has many other

possible causes. Some cases are idiopathic, i.e., of unknown cause. It is the 11th most

common cause of death in the United States and is most common among people ages 45

– 75. Most cases are a result of alcoholism, but toxins, biliary destruction, hepatitis, and a

number of metabolic conditions may stimulate the destruction process. In the

Philippines, this disease ranks as the 13th leading cause of death and has affected 126, 826

Filipinos in the year 2005. Locally, liver cirrhosis is the 17th leading cause of death.

Gastroenteritis (also known as gastro, gastric flu and stomach flu, although

unrelated to influenza) is inflammation of the gastrointestinal tract, involving both the

stomach and the small intestine resulting in acute diarrhea. The inflammation is caused

most often by infection with certain viruses, less often by bacteria or their toxins,

parasites, or adverse reaction to something in the diet or medication. Worldwide,

inadequate treatment of gastroenteritis kills 5 to 8 million people per year, and is a

leading cause of death among infants and children under 5.

At least 50% of cases of gastroenteritis as foodborne illness are due to norovirus. Another

20% of cases, and the majority of severe cases in children, are due to rotavirus.

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Risk factors include consumption of improperly prepared foods or contaminated water

and travel or residence in areas of poor sanitation. It is also common for river swimmers

to become infected during times of rain as a result of contaminated runoff water. The

incidence is 1 in 1,000 people. It can also be classified as either viral or bacterial. A

major cause of morbidity and mortality in developing nations, gastroenteritis occurs in

people of all ages. In the United States, this disorder ranks second to the common colds

as a cause of lost work time and fifth as the cause of death among young children. It can

also be life-threatening in elderly and debilitated patients. This disorder belongs to one of

the ten causes of morbidity and mortality in the Philippines. Locally, it ranks 14 th among

the leading causes of death.

Our patient, given the name “T2”, was chosen as the subject for this case study

because of his condition. He acquired schistosomiasis which led to the removal of his

spleen and then resulted to liver cirrhosis.

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OBJECTIVES

General Objectives:

To conduct a thorough and comprehensive study about the Mr. T2’s disease

according to the data that was gathered by conducting a series of interviews and through

the use of data gathered from extensive research.

Specific Objectives:

To organize our patient’s data for the establishment of good background

information

To show the family health history as well as the history of past and present illness

for the knowledge of what could be the predisposing factors that might contribute

to the patient's illness

To present the family’s genogram containing information that will help out in

tracing any hereditary risk factors

To trace the psychological development of our patient through analysis of different

developmental theories with comparison to the patient’s data

To give different definitions of the complete diagnosis of our patient for better

understanding of unfamiliar terms

To present the data from the physical assessment performed on our patient using

the cephalocaudal approach for a good overview of her over-all health

To discuss the human anatomy and physiology of the systems involved in the

disease process of our patient

To identify the symptoms, predisposing and precipitating factors that contribute to

the present illness of the patient

To organize a flow chart showing the pathophysiology of liver cirrhosis as well as

its relation to acute gastroenteritis for a clear visualization of how this condition

affects a person

To list the different orders of the physicians assigned to our patient together with

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their rationale for a general knowledge of what consists of the medical

management for liver cirrhosis

To present the different results of our patient’s diagnostic exams together with

comparisons of normal values for the understanding of what changes during the

disease

To list the different drugs used by our patient to have a better understanding of its

actions and indications

To analyze the different nursing theories applicable to our patient

To formulate specific, measurable, attainable, realistic and time-bounded nursing

care plans

To impart appropriate health teachings specifically for the patient to promote

wellness

To present an appropriate discharge plan for our patient

To have an over-all conclusion and recommendation about the case study

4

PATIENT’S DATA

Patient’s Code name: Mr. T2

Age: 24 years old

Sex: Male

Nationality: Filipino

Religion: Roman Catholic

Civil Status: Single

Occupation: Technician

Ward: Med CP Ward

Hospital No: 1091204

Date of Admission: April 15, 2009

Time of Admission: 12:35 am

Vital Signs on Admission:

BP – 110/ 80mmHg

RR –21 bpm

Temp: 36.7ºC

PR: 76bpm

Mode of Arrival: Stretcher

Admitting Doctor: Dr. Carl Hill N. Florida

Admitting Diagnosis: Liver Cirrhosis: A.G.E. with moderate Dehydration

5

FAMILY BACKGROUND

Mr. T2, a 24-year old male, was born in Davao City on September 15, 1984. He is

currently residing at Estores Village, Davao City. They are 7 in the family including his

parents. He is the third child among the five children. Our patient was completely

immunized since he received the needed immunizations before he reached 1 year old.

He enrolled in elementary at B.F. Coucuera Elementary School at Malagamot,

Panacan, Davao City. He finished high school at University of Mindanao at Ilang,

Tibungco, Davao City. Our patient was not able to study in college because of financial

constraints. Our patient used to work in Ateneo College as a technician in the

Engineering Department. At present, he is working at Notre Dame of Marbel as a

technician.

Upon interview, Mr. T2 said that no one in his family had the same disease.

LIFESTYLE

Mr. T2 described his workplace as having a stressful environment as well as his

job. He works six days a week and verbalized that he was always assigned to different

departments and mostly he works more than his hours of duty. He reported that when he

is not working, he usually stays at his boarding house sleeping and eating.

When asked about how he usually spends his days, Mr. T2 was able to formulate

a schedule that would describe his activities of daily living. He would wake up at 6:00

am. The first thing he would do is to take a bath, change to his working clothes then takes

6

his breakfast. He arrives at his workplace at around 7:30 am. It is in there where he does

his work. His duty ends at 5:00 pm but he usually goes home at 9:00 or 10:00 pm because

of overtime. When he arrives at home, he sometimes skips his meals and goes directly to

bed.

DIET

Mr. T2 verbalized that he is fond of eating chicken, egg, hotdog, meat and he

seldom eats vegetables. He admits that he is an occasional drinker but does not smoke.

He said that he only drinks alcoholic beverages whenever there are occasions such as

birthdays and fiestas.

HISTORY OF PATIENT’S PAST ILLNESS

According to Mr. T2, he was hospitalized four times. His first hospitalization was

on 2005 due to melena. He then underwent endoscopy and was diagnosed with ulcer.

When asked about the medicines he took, he immediately said that he cannot recall the

names of those medicines.

His second hospitalization was on 2006 due to schistosomiasis. His chief

complaints were abdominal pain and fatigue and he was not able to determine the real

cause why he acquired such disease. In addition, his diagnostic exam showed that he has

enlarged spleen which needed immediate attention. Due to this, he had undergone

splenectomy on the same year. After the said procedure, he was not able to have follow-

up check-ups.

7

His third hospitalization was on March 15, 2009. His chief complaint was melena

and had an admitting diagnosis of Upper Gastrointestinal Bleeding. During this

hospitalization, he was also diagnosed with Liver Cirrhosis. Among complaints were

yellowish discoloration of skin, insomnia, recurrent fever, fatigue, abdominal pain,

weight loss, nosebleed and nausea.

HISTORY OF PRESENT ILLNESS

Mr. T2’s fourth hospitalization was on April 15, 2009 due to his present illness

which is Acute Gastroenterisits. He verbalized that he experienced diarrhea since

March19, 2009. Three days prior to his admission, he experienced an onset of

undocumented fever associated with diarrhea. Then a day prior to his admission, he had

five episodes of loose bowel movement with blood streaked stools thus prompted the

consult.

EFFECTS OF ILLNESS TO THE FAMILY

During the interview, Mr. T2 was asked regarding the effects of his illness to him

and to his family. He directly said that it greatly affected their family especially on

financial and emotional matters. He said that it is understandable why it affected them

financially because of his hospitalizations. Emotionally they are affected because of the

emotional stress they encounter everytime Mr. T2 is hospitalized.

8

DEVELOPMENTAL DATA

Theorist Theory Stage Result and Justification

Erik Erikson’s

Psychosocial

Theory of

Development

Source:

Fundamentals of Nursing, 3rd EditionBy:Sue C. DelaunePatricia K. Ladner

Fundamentals of Nursing, 7th

EditionBy:Barbara Kozier, Glenora Erb, Audrey Berman, Sherlee Snyder

Erik Erikson

theorized that

development is a

lifelong process and

does not end with

the cessation of

adolescence. Just as

physical growth

patterns can be

predicted, certain

psychosocial tasks

must be mastered in

each developmental

stage. The greater

the task

achievement, the

healthier the

personality of the

person. However,

failure to achieve a

Intimacy Vs. Isolation

(18 to 25 years old)

Individuals feel

established as adults and

autonomous from their

families. A person

develops closeness and

committed meaningful

relationships with other

people. They see

themselves as well-

defined but still feel the

need to prove themselves

to their parents. They see

this as the time for

growing and building time

for the future.

A person with a poor

sense of self tend to have

less committed

The patient has

positively achieved

this stage of

development. He

has the ability to

keep a good

relationship with

other people

especially to the

other sex. He said

that he is very

much happy and

contented with his

current girlfriend

because they were

able to establish an

intimate

relationship for

almost 4 years now.

He is thankful

because they both

help each other’s

needs and wants

since they both

matured together.

Also, he said that

he is one lucky guy

9

task influences the

person’s ability to

achieve the next

task. The resolution

of the conflicts at

each stage enables

the person to

function effectively

in society.

relationships and are more

likely to suffer emotional

isolation, loneliness, and

depression.

A positive outcome in this

stage is achieved if the

person establishes an

intimate relationship to

another person, accepts

sexual behavior as

desirable, and makes a

commitment to a

relationship even at times

of stress and sacrifice.

for having a family

who cares for him

so much and

supports whatever

his decisions will

be. Without doubt

T2 did not have any

regrets in all his

decisions and

things he made

whether it be bad or

good for as long as

it’ll serve as a

lesson for him.

T2 said that even

though he is stress

from his

workloads, he has

his inspiration and

is still loved by

many. He added

that he is also ready

to marry his current

girlfriend as soon

as he is able.

Lawrence

Kohlberg’s

Lawrence

Kohlberg’s theory

Level II: Conventional

In this level, the person is

T2 is a nice and

considerate person

10

Stages of

Moral

Development

Source:

Fundamentals

of Nursing,

3rd Edition

By:

Sue C. Delaune

Patricia K.

Ladner

Fundamentals

of Nursing, 7th

Edition

By:

Barbara Kozier,

Glenora Erb,

Audrey

Berman,

Sherlee Snyder

specifically

addresses moral

development in

children and adults.

The morality of an

individual’s

decision was not

Kohlberg’s concern;

rather, he focused

on the reasons the

individual makes a

decision. His model

states that a

person’s ability to

make moral

judgments and

behave in a morally

correct manner

develops over a

period of time.

concerned with

maintaining expectations

and rules of the family,

group, nation, or society.

The person values

conformity, loyalty, and

active maintenance of

social order and control.

Stages:

Interpersonal

Concordance

Orientation:

Decisions and behavior

are based on concerns

about others’ reaction; the

person wants others’

approval or a reward.

Law-and-Order

Orientation:

The person wants

established rules and the

reason for decisions and

behavior is that social and

sexual rules and traditions

demand the response.

according to his

older brother. He

prefers to cater to

the needs of his

family before

tending to his own.

Whenever

problems or

decisions come

along, he puts

himself to the shoes

of the others. Thus,

understanding the

feelings and

concerns of others

like his family and

friends. He abides

and maintains law

and order by

following the rules,

doing one’s duty,

and respecting

authority.

11

Robert

Havighurst’s

Developmental

Milestones

Theory

Source:

Fundamentals of Nursing, 3rd EditionBy:Sue C. DelaunePatricia K. Ladner

Fundamentals of Nursing, 7th

EditionBy:Barbara Kozier, Glenora Erb, Audrey Berman, Sherlee Snyder

Havighurst

theorized that there

are six

developmental

stages of life, each

with essential tasks

to be achieved.

Mastery of a task in

one developmental

stage is essential for

mastery of tasks in

subsequent stages.

A successful

achievement of a

task leads to

happiness and to

success with later

tasks. However,

failure leads to

unhappiness in the

individual and

difficulty with later

tasks.

Early Adulthood (19 to 29 years)

This stage in a person’s

life is concerned with the

achievement of the

following tasks:

Selecting a

mate

Learning to live

with a partner

X Starting a

family

X Rearing

children

Managing a

home

Getting started

in an

occupation

Taking on

civic

responsibility

Finding a

congenial

T2 is not yet

married but he has

plans on marrying

his girlfriend as

soon as he can save

enough money.

He was not able to

achieve the third

and fourth task

since he is still

single with no

children to attend

to. Though he is

busy, he still finds

time to help his

parents in

maintaining the

cleanliness of the

house. He is

currently working

as a technician at

Notre Dame of

Marbel in order to

attend to the wants

and needs of his

family. He is also

aware of his

responsibilities as a

Filipino citizen. For

one, he is a

registered voter,

12

social group second, pays his

taxes and abides

the laws. He

claimed that he

doesn’t find it hard

to interact with his

neighbors because

they are

approachable and

helpful every time

they may have

some problems.

Thus, in return, he

and his family also

render help when

needed. “It’s a give

and take

relationship”, T2

added. He is not a

member of any

social institution,

since he is more

focused with his

job.

13

DEFINITION OF COMPLETE DIAGNOSIS

Liver Cirrhosis

A chronic hepatic disease, cirrhosis is characterized by diffuse destruction and

fibrotic regeneration of hepatic cells. As necrotic tissue yields to fibrosis, this disease

alters liver structure and normal vasculature, impairs blood and lymph flow, and

ultimately causes hepatic insufficiency.

Source: Handbook of Medical-Surgical Nursing 3rd Edition by Springhouse

Liver Cirrhosis

Cirrhosis is a consequence of chronic liver disease characterized by replacement

of liver tissue by fibrous scar tissue as well as regenerative nodules (lumps that occur as a

result of a process in which damaged tissue is regenerated) leading to progressive loss of

liver function.

Source: Blackwell’s Dictionary of Nursing 5th Edition

Liver Cirrhosis

Cirrhosis is a chronic, degenerative disease in which normal liver cells are

damaged and are then replaced by scar tissue.

Source: http://www.answers.com/topic/cirrhosis

AGE with Mild Dehydration

A self-limiting disorder, gastroenteritis is an inflammation of the stomach and

small intestine. The bowel reacts to any of the varied causes of gastroenteritis with

hypermotility, producing severe diarrhea and secondary depletion of intracellular fluid. is

the loss of water from the body. With mild dehydration, a related disorder where both

fluids and salts are depleted in the cells or volume depletion.

Source: http://www.answers.com/topic/cirrhosis

14

AGE with Mild Dehydration

Gastroenteritis is inflammation of the gastrointestinal tract, involving both the

stomach and the small intestine and resulting in acute diarrhea. With a relative

deficiency of water molecules in relation to other dissolved solutes.

Source: http://en.wikipedia.org/wiki/Gastroenteritis

Gastroenteritis

A self- limiting disorder, gastroenteritis is an inflammation of the stomach and

small intestine.

Source: Handbook of Medical-Surgical Nursing 3rd Edition by Springhouse

Liver Cirrhosis; AGE with mild dehydration

A chronic hepatic disease, cirrhosis is characterized by diffuse destruction and

fibrotic regeneration of hepatic cells. As necrotic tissue yields to fibrosis, this disease

alters liver structure and normal vasculature, impairs blood and lymph flow, and

ultimately causes hepatic insufficiency.

A self-limiting disorder, gastroenteritis is an inflammation of the stomach and

small intestine. The bowel reacts to any of the varied causes of gastroenteritis with

hypermotility, producing severe diarrhea and secondary depletion of intracellular fluid. is

the loss of water from the body. With mild dehydration, a related disorder where both

fluids and salts are depleted in the cells or volume depletion.

15

PHYSICAL ASSESSMENT

Patient’s Name: Mr. T2

Age: 24 y.o.

Sex: Male

Ward: Med Cp (DMC)

General Survey:

Our patient, Mr. T2 was assessed on April 17, 2009 at 5:00pm. He was received

lying on bed awake, conscious and coherent. He has an ongoing IVF of D5.3 NaCl 1 liter

regulated @120cc/hr infusing well at L metacarpal vein at 400cc level. He weighs 46

kilograms and he has an ectomorphic body structure. He was responsive and cooperative

when asked.

Vital signs

4:00 pm

BP- 110/60 mmHg

PR- 78 bpm

RR- 24 bpm

Temp.- 37.6 °C

16

Skin

Mild jaundice was noted on his skin. He has good skin turgor as skin goes back to

its previous state after being pinched and with a capillary refill of 2 seconds. He has dry

skin with a rough texture. Nails were not properly trimmed and traces of dirt were noted.

Upon palpation, the skin on his forearm is warm.

Head

Our patient’s head is normocephalic. Presence of hair was noted in the head and

in the upper and lower extremities. Lesions, bleeding and bruises were not seen upon

inspection.

Eyes

The sclera is moist and yellowish in color. The iris appears to be black on both

eyes. He has an isocuric pupil reaction of 2mm; round and reactive to light and

accommodation. He verbalized that he can see both near and far objects. Both eyes move

in unison, no signs of scratches and discharges on both eyes noted. Sunken eyeballs are

also noted.

Ears

The shape of the pinnaes are oval and with no discharges noted. Upper margin of

the pinnaes are in line with the outer canthi of the eyes. Ears are firm and non-tender.

Signs of lesions, lacerations, swelling and bruises were not seen upon inspection. He was

17

able to repeat a sentence when it was softly said behind his ears, which reveals that he

does not have any hearing problems.

Nose

External surface of the nose is smooth and oily. Nasolabial folds are symmetrical.

Nostrils are also symmetrical with no flaring and discharges noted. Nasal hairs are

present upon inspection. Nasal septum is not deviated. Both nostrils are patent. No signs

of tenderness were noted. Patient was able to distinguish the smell of rubbing alcohol and

female perfume while eyes were closed.

Mouth

Gums and buccal mucosa are pinkish in color. Tongue is in the midline of the

mouth. Tonsils are not inflamed. No signs of inflammation and laceration on the uvula.

Bleeding, ulceration and swelling were not seen upon inspection. Patient was on diet as

tolerated and does not have any difficulty eating and swallowing.

Neck

The neck of our patient can move easily without any difficulty, which includes

right and left lateral, right and left rotation, flexion and hyperextension. Neck can

properly support the head. No signs of enlargement and masses on the thyroid. Carotid

pulse is palpable. No signs of swelling or enlargement of the lymph nodes. No

deformities noted.

18

Chest and Lungs

Chest muscle expansion during inspiration and relaxation during expiration are

symmetrical and painless. There were no presence of scars and lesions. He was not in

respiratory distress. Respiratory rate is 24 cycles per minute and rhythm was regular.

Breath sounds were clear on both lungs but upon observing he coughs and whitish

sputum was noted upon coughing.

Abdomen

Patient’s abdomen is flat upon inspection. Palpation was contraindicated due to

his disease. But according to him, he feels a stabbing pain in the hypogastric region on

his abdomen because of presence of dyspepsia. A scar was noted starting in the xyphoid

process until above the mons pubis. Hyperactive bowel movements were noted at 16

sounds in one full minute.

Genito-Urinary

Patient refused to be assessed on his genital area. However, patient verbalized no

pain or difficulty upon urination and defecation. His total urine output for 8 hours was

about 640cc and was able to defecate six times with an output of approximately 1500cc.

Upper extremities

Patient’s upper limbs, shoulders and arms were symmetrical. No tenderness noted

on the bones of the wrist and fingers. No deformities and swelling noted. He could freely

move his shoulders. The patient has a weak grip when he was asked to squeeze one of the

19

student nurse’s hands. No structural deviations noted. T2 was undergoing venoclysis with

IVF of D5.3NaCl 1 liter regulated @120cc/hr infusing well at L metacarpal vein at 400cc

level.

Lower Extremities

Both legs of the patient are symmetrical and can stretch, flex, rotate, extend and

bend without any difficulty. No signs of deformities, lesions, lacerations, bruises and

bleeding were seen upon inspection. Patient has difficulty ambulating because of fatigue,

he needs assistance when he goes to the comfort room.

20

ANATOMY AND PHYSIOLOGY

Gastrointestinal Tract[image from: http://www.lessonsonthelake.com/_images//j0438737.jpg]

The gastrointestinal tract (GIT) consists of a hollow muscular tube starting from

the oral cavity, where food enters the mouth, continuing through the pharynx,

oesophagus, stomach and intestines to the rectum and anus, where food is expelled. There

are various accessory organs that assist the tract by secreting enzymes to help break down

food into its component nutrients. Thus the salivary glands, liver, pancreas and gall

bladder have important functions in the digestive system. Food is propelled along the

length of the GIT by peristaltic movements of the muscular walls.

The primary purpose of the gastrointestinal tract is to break down food into

nutrients, which can be absorbed into the body to provide energy. First food must be

ingested into the mouth to be mechanically processed and moistened. Secondly, digestion

occurs mainly in the stomach and small intestine where proteins, fats and carbohydrates

are chemically broken down into their basic building blocks. Smaller molecules are then

absorbed across the epithelium of the small intestine and subsequently enter the

circulation. The large intestine plays a key role in reabsorbing excess water. Finally,

undigested material and secreted waste products are excreted from the body via

defecation (passing of faeces).

21

Cross-section of the small intestine[image from: http://z.about.com/d/coloncancer/1/0/Y/3/Overview.png]

The digestive tract, from the esophagus to the anus, is characterized by a wall

with four layers, or tunics. Here are the layers, from the inside of the tract to the outside:

The mucosa is a mucous membrane that lines the inside of the digestive tract from

mouth to anus. Depending upon the section of the digestive tract, it protects the

GI tract wall, secretes substances, and absorbs the end products of digestion. It is

composed of three layers:

o The epithelium is the innermost layer of the mucosa. It is composed of

simple columnar epithelium or stratified squamous epithelium. Also

present are goblet cells that secrete mucus that protects the epithelium

from digestion and endocrine cells that secrete hormones into the blood.

o The lamina propria lies outside the epithelium. It is composed of areolar

connective tissue. Blood vessels and lymphatic vessels present in this

layer provide nutrients to the epithelial layer, distribute hormones

produced in the epithelium, and absorb end products of digestion from the

22

lumen. The lamina propria also contains the mucosa-associated lymphoid

tissue (MALT), nodules of lymphatic tissue bearing lymphocytes and

macrophages that protect the GI tract wall from bacteria and other

pathogens that may be mixed with food.

o The muscularis mucosae, the outer layer of the mucosa, is a thin layer of

smooth muscle responsible for generating local movements. In the

stomach and small intestine, the smooth muscle generates folds that

increase the absorptive surface area of the mucosa.

The submucosa lies outside the mucosa. It consists of areolar connective tissue

containing blood vessels, lymphatic vessels, and nerve fibers.

The muscularis (muscularis externa) is a layer of muscle. In the mouth and

pharynx, it consists of skeletal muscle that aids in swallowing. In the rest of the

GI tract, it consists of smooth muscle (three layers in the stomach, two layers in

the small and large intestines) and associated nerve fibers. The smooth muscle is

responsible for movement of food by peristalsis and mechanical digestion by

segmentation. In some regions, the circular layer of smooth muscle enlarges to

form sphincters, circular muscles that control the opening and closing of the

lumen (such as between the stomach and small intestine).

The serosa is a serous membrane that lines the outside of an organ. The following

serosae are associated with the digestive tract:

o The adventitia is the serous membrane that lines the esophagus.

o The visceral peritoneum is the serous membrane that lines the stomach,

large intestine, and small intestine.

o The mesentery is an extension of the visceral peritoneum that attaches the

small intestine to the rear abdominal wall.

o The mesocolon is an extension of the visceral peritoneum that attaches the

large intestine to the rear of the abdominal wall.

o The parietal peritoneum lines the abdominopelvic cavity (abdominal and

pelvic cavities). The abdominal cavity contains the stomach, small

intestine, large intestine, liver, spleen, and pancreas. The pelvic cavity

contains the urinary bladder, rectum, and internal reproductive organs.

23

Motility

The gastrointestinal tract generates motility using smooth muscle subunits linked by gap

junctions. These subunits fire spontaneously in either a tonic or a phasic fashion. Tonic

contractions are those contractions that are maintained from several minutes up to hours

at a time. These occur in the sphincters of the tract, as well as in the anterior stomach.

The other type of contractions, called phasic contractions, consist of brief periods of both

relaxation and contraction, occurring in the posterior stomach and the small intestine, and

are carried out by the muscularis externa.

Stimulation

The stimulation for these contractions likely originates in modified smooth muscle cells

called interstitial cells of Cajal. These cells cause spontaneous cycles of slow wave

potentials that can cause action potentials in smooth muscle cells. They are associated

with the contractile smooth muscle via gap junctions. These slow wave potentials must

reach a threshold level for the action potential to occur, whereupon Ca2+ channels on the

smooth muscle open and an action potential occurs. As the contraction is graded based

upon how much Ca2+ enters the cell, the longer the duration of slow wave, the more

action potentials occur. This in turn results in greater contraction force from the smooth

muscle. Both amplitude and duration of the slow waves can be modified based upon the

presence of neurotransmitters, hormones or other paracrine signaling. The number of

slow wave potentials per minute varies based upon the location in the digestive tract. This

number ranges from 3 waves/min in the stomach to 12 waves/min in the intestines.

Contraction Patterns

The patterns of gastrointestinal contraction as a whole can be divided into two distinct

patterns, peristalsis and segmentation. Occurring between meals, the migrating motor

complex is a series of peristaltic wave’s cycles in distinct phases starting with relaxation

followed by an increasing level of activity to a peak level of peristaltic activity lasting for

5-15 minutes. This cycle repeats ever 1.5-2 hours but is interrupted by food ingestion.

The role of this process is likely to clean excess bacteria and food from the digestive

system.

24

Peristalsis

Peristalsis is the second of the three patterns and is one of the patterns that occur during

and shortly after a meal. The contractions occur in wave patterns traveling down short

lengths of the GI tract from one section to the next. The contractions occur directly

behind the bolus of food that is in the system, forcing it toward the anus into the next

relaxed section of smooth muscle. This relaxed section then contracts, generating smooth

forward movement of the bolus at between 2-25 cm per second. This contraction pattern

depends upon hormones, paracrine signals, and the autonomic nervous system for proper

regulation.

Segmentation

The third contraction pattern is segmentation, which also occurs during and shortly after a

meal within short lengths in segmented or random patterns along the intestine. This

process is carried out by longitudinal muscles relaxing while circular muscles contract at

alternating sections thereby mixing the food. This mixing allows food and digestive

enzymes to maintain a uniform composition, as well as to ensure contact with the

epithelium for proper absorption.

Secretion

Every day, seven liters of fluid are secreted by the digestive system. This fluid is

composed of four primary components: ions, digestive enzymes, mucus, and bile. About

half of these fluids are secreted by the salivary glands, pancreas, and liver, which

compose the accessory organs and glands of the digestive system. The rest of the fluid is

secreted by the GI epithelial cells.

25

Ions

The largest component of secreted fluids is ions and water, which are first secreted and

then reabsorbed along the tract. The ions secreted primarily consist of H+, K+, Cl-,

HCO3- and Na+. Water follows the movement of these ions. The GI tract accomplishes

this ion pumping using a system of proteins that are capable of active transport,

facilitated diffusion and open channel ion movement. The arrangement of these proteins

on the apical and basolateral sides of the epithelium determines the net movement of ions

and water in the tract.

H+ and Cl- are secreted by the parietal cells into the lumen of the stomach creating acidic

conditions with a low pH of 1. H+ is pumped into the stomach by exchanging it with K+.

This process also requires ATP as a source of energy; however, Cl- then follows the

positive charge in the H+ through an open apical channel protein.

HCO3- secretion occurs to neutralize the acid secretions that make their way into the

duodenum of the small intestine. Most of the HCO3- comes from pancreatic acinar cells

in the form of NaHCO3 in a watery solution. This is the result of the high concentration

of both HCO3- and Na+ present in the duct creating an osmotic gradient to which the

water follows.

Digestive Enzymes

The second vital secretion of the GI tract is that of digestive enzymes that are secreted in

the mouth, stomach and intestines. Some of these enzymes are secreted by accessory

digestive organs, while others are secreted by the epithelial cells of the stomach and

intestine. While some of these enzymes remain embedded in the wall of the GI tract,

others are secreted in an inactive proenzyme form. When these proenzymes reach the

lumen of the tract, a factor specific to a particular proenzyme will activate it. A prime

example of this is pepsin, which is secreted in the stomach by chief cells. Pepsin in its

secreted form is inactive (pepsinogen). However, once it reaches the gastic lumen it

becomes activated into pepsin by the high H+ concentration, becoming a enzyme vital to

digestion. The release of the enzymes is regulated by neural, hormonal, or paracrine

signals. However, in general, parasympathtic stimulation increases secretion of all

digestive enzmes.

26

Mucus

Mucus is released in the stomach and intestine, and serves to lubricate and protect the

inner mucosa of the tract. It is composed of a specific family of glycoproteins termed

mucins and is generally very viscous. Mucus is made by two types of specialized cells

termed mucus cells in the stomach and goblet cells in the intestines. Signals for increased

mucus release include parasympathetic innervations, immune system response and

enteric nervous system messengers.

Bile

Bile is secreted into the duodenum of the small intestine via the common bile duct. It is

produced in liver cells and stored in the gall bladder until release during a meal. Bile is

formed of three elements: bile salts, bilirubin and cholesterol. Bilirubin is a waste product

of the breakdown of hemoglobin. The cholesterol present is secreted with the feces. The

bile salt component is an active non-enzymatic substance that facilitates fat absorption by

helping it to form an emulsion with water due to its amphoteric nature. These salts are

formed in the hepatocytes from bile acids combined with an amino acid. Other

compounds such as the waste products of drug degradation are also present in the bile.

Regulation

The digestive system has a complex system of motility and secretion regulation which is

vital for proper function. This task is accomplished via a system of long reflexes from the

central nervous system (CNS), short reflexes from the enteric nervous system (ENS) and

reflexes from GI peptides working in harmony with each other.

27

ETIOLOGY

Predisposing Factors

Factor Rationale Present or Absent JustificationExtremes of age Extremes of age can

increase the susceptibility of getting ill with AGE

Absent Patient is an adult and does not belong to the pediatric or geriatric classification.

Location – Philippines

The Philippines is considered as one of the South-East Asian countries that have high numbers of E. histolytica.

Present Patient has lived in the Philippines for a long period of time.

Race - Filipino The Filipino culture is fond of eating without utensils

Present Patient is a Filipino, and has lived in the Philippines his entire life so far.

28

Precipitating Factors

Factor Rationale Present or Absent JustificationNegligence to observe proper hand washing

Failure to do proper hand washing leads to increased risk of ingesting bacteria

Present Patient verbalized that he does not wash his hands as often as needed.

Facial contact with surfaces containing bacteria.

Facial contact, especially with the mouth, can lead to increased risk of ingesting bacteria

Present Patient verbalized that for a few days, he stayed in a ward where he got ill with Acute Gastroenteritis.

Ingestion poisonous plants

Poisonous plants can cause disturbances in the GI tract leading to AGE and other GI disturbances.

Absent Patient did not ingest any known poisonous plant.

Food allergens Food allergies can also cause GI disturbances

Absent Patient does not have any food allergies.

Drug reactions from antibiotics

Antibiotic-associated diarrhea (AAD)can be related to AGE

Absent Patient has not been examined for AAD. Assumption of the presence of this risk factor cannot be done.

29

SYMPTOMATOLOGY

Symptom Rationale Present or Absent JustificationAbdominal Pain Pain is felt from the

gas that accumulates in the GI tract.

Present Patient verbalized a confirmatory remark that he indeed experienced the symptom.

Nausea and Vomiting

Nausea and Vomiting is caused by the increased motility of the GI tract.

Present Patient verbalized a confirmatory remark that he indeed experienced the symptom.

Fatigue Fatigue is caused by the rapid losing of electrolytes.

Present Patient verbalized a confirmatory remark that he indeed experienced the symptom.

Diarrhea Diarrhea is caused by the increased peristalsis of the intestines.

Present Patient verbalized a confirmatory remark that he indeed experienced the symptom.

Dehydration Dehydration is also caused by rapid loss of body fluids.

Present Intake and output documents revealed that this symptom is present.

Malaise Malaise is the result of the lack of fluids in the brain and muscles of the body.

Present Patient verbalized a confirmatory remark that he indeed experienced the symptom.

30

31

Ingestion of bacteria

Direct invasion of the bowel wall

Stimulation and destruction of mucosal lining of the bowel wall

ulceration

Attempted defecation (tenesmus)

Digestive & absorptive malfunction

Pain

GI bleeding

melena

hematochezia

hematemesis

Excessive gas formation

GI distention

Nausea & vomiting

Flatus

Endotoxins are released

Predisposing factor:

Extremes of ageLocation – PhilippinesRace - Filipino

Precipitating factor:

-Negligence to observe proper hand washing-Facial contact with surfaces containing bacteria.-Ingestion poisonous plants-Food allergens-Drug reactions from antibiotics

PATHOPHYSIOLOGY

32

Secretion of F&E in the

intestinal lumen

Increase peristaltic movement

Increase secretionof Cl & HCO3

ions in the bowel

Hyperactive bowel sound (borborygmi)

Mild diarrhea (2-3 stools)

F&E imbalance

hypernatremiaIncrease protein in

the lumen

Large intestine is overwhelmed & unable to

reabsorb the lost fluid

Intense diarrhea (>10x) (watery stool)

Serious fluid volume deficit

Hypovolemic shock

Death

Hypotension

Acute gastroenteritis is usually caused by bacteria and protozoan. In the Philippines, one

of the most common causes of acute gastroenteritis is E. histolytica. The pathologic process starts

with ingestion of fecally contaminated food and water. The organism affects the body through

direct invasion and by endotoxin being released by the organism. Through these two processes

the bowel mucosal lining is stimulated and destroyed the eventually lead to attempted defecation

or tenesmus as the body tries to get rid of the foreign organism in the stomach.

The client with acute gastroenteritis may also report excessive gas formation that may

leads to abdominal distention and passing of flatus due to digestive and absorptive malfunction in

the system. Feeling of fullness and the increase motility of the gastrointestinal tract may progress

to nausea and vomiting and increasing frequency of defecation. Abdominal pain and feeling of

fullness maybe relieved only when the patient is able to pass a flatus.

As the destruction of the bowel continues the mucosal lining erodes due to toxin, direct

invasion of the organism and the action of the hydrochloric acid of the stomach. As the protective

coating of the stomach erodes the digestive capabilities of the acid helps in destroying the

stomach lining. Pain or tenderness of the abdomen is then felt by the patient. When the burrows

or ulceration reaches the blood vessels in the stomach bleeding will be induced. Dysentery may

be characterized by melena or hematochezia depending on the site and quantity of bleeding that

may ensue. Signs of bleeding may be observed also through hematemesis.

As the bowel is stimulated by the organism and its toxin, the intestinal tract secretes

water and electrolytes in the intestinal lumen. The body secretes and therefore lost Chloride and

bicarbonate ions in the bowel as the body try to get rid of the organism by increasing peristalsis

and number of defecation. Sodium and water reabsorption in the bowel is inhibited with the lost

of the two electrolytes.

Mild diarrhea is characterized by 2-3 stool, borborygmi (hyperactive bowel sound),fluid

and electrolyte imbalance and hypernatremia. When the condition continue to progress, protein in

the body is excreted to the lumen that further decreases the reabsorption and the body become

overwhelmed that leads to intense diarrhea with more than 10 watery stool. Serious fluid volume

deficit may lead to hypovolemic shock and eventually death.

33

DOCTOR’S ORDER

DATE DOCTOR'S ORDER RATIONALE REMARKS

April 15, 20092:45 pm

Pls. admit under the white service at med main level II

The patient is in need of medical attention so she is admitted in Davao Medical Center Hospital

DONE

Secure consent for care For legal purposes and to ensure that the client understands the nature of the treatment

DONE

TPRq4˚ Vital signs are recorded to obtain patients baseline data and are useful for further management. A temperature higher than normal may indicate the development of infection. Pulse & respiration is taken to watch out for tachycardia - a sign of hemorrhage & dehydration.

DONE

Labs:CBC with pc, Blood typing, PT with INR, Urinalysis, Creatine, Potassium, Sodium, ECG- 12 leads, Fecalysis

These entire lab tests are performed to screen for alteration and to serve as a baseline data for future comparison.

DONE

Start venoclysis with D5 0.3 NaCl to run for 8 hours fast drip 200 cc now

Serves as a route for IVTT medications and replaces fluid and electrolyte losses due to frequent loose bowel movement

DONE

Meds:1. Essentiale forte tab 1 tab Indicated for liver disorders

DONE

34

2. Ranitidine 50 mg IVTT now every 8 hours

3. Hyoscine amp 1 amp IVTT now then every 8 hours

4. Metronidazole 500 mg per amp 1 amp every 8 hours ANST

Short term treatment for gastric ulcer

Treatment for abdominal pain

Treatment for bacterial infection

I & O every shift To determine if the patient’s intake is closely equal to his output

DONE

Refer Referral is done to correct unusualities as soon as possible and to inform the attending physician of the patient's condition.

DONE

April 15, 20092:45 pm

Transfer to blue service, please inform service

To render specific treatment for gastro cases

DONE

April 16, 20096:15 pm

Dx: stool culture To ensure that the needed specimen will be obtained for early examination and diagnosis

DONE

For colonoscopy scheduling To aware the NOD and to schedule for the endoscopic examination of the colon

DONE

Transfer to blue service ( gastro)

To render specific treatment for gastro cases

DONE

April 16, 200910:25 am

Dx for CT scan of the whole abdomen

To test the amount of glucose in the blood. An abnormal may signify further management.

DONE

For HBsAg, Anti- HAV To establish a diagnosis of hepatits B infection and to assess immune status in naturally infected and experimentally vaccinated individuals

Continue all meds To continue medication therapy and avoid further complications

Refer Referral is done to correct DONE

35

unusualities as soon as possible and to inform the attending physician of the patient’s condition

April 16, 2009

Admit to CP- Gym (level II) For further specialization of management

DONE

April 17, 2009

(+) BM 7x

3:55 am

Still for colonoscopy scheduling

To follow up previous order DONE

Follow up stool culture To ensure that the needed specimen will be obtained for early examination

DONE

Continue meds. To continue medication therapy and avoid further complications

DONE

DONERefer Referral is done to correct

unusualities as soon as possible and to inform the attending physician of the patient’s condition

DONE

36

Diagnostic Exams

Ultrasound ReportDate: March 19, 2009

Result Findings:The right hepatic lobe is small relative to the left lobe. The liver exhibits a

diffusely coarsened parenchyma with a slightly irregular external outline. No focal mass lesion seen. There are no dilated intrahepatic ducts.

The gall bladder is normal in size and configuration. The walls are not thickened. There are no intraluminal echoes nor calculus seen.

There are no abnormal intraluminal masses seen within the common bile duct. It’s largest antero-posterior diameter is 0.25 cm.

There are no abnormal masses or enlarged lymph nodes in the vicinity of the abdominal aorta.

The pancreas is normal in size with the following dimensions: head = 1.55 cm, neck = 0.83 cm, body/tall = 1.35 cm. it exhibits a homogenous parenchymal echopattern and a regular outline, no focal mass lesions seen.

The spleen is surgically absent.

Length (cm) Width (cm) Thickness (cm) Cortical Thickness (cm)Right Kidney 11.75 5.87 5.82 1.88Left Kidney 11.43 5.65 5.50 1.74

There is no significant disparity in the size, shape and location of both kidneys. They exhibit a isoechoic parenchymal echopattern relative to that of the liver and spleen. The pelvocalyceal systems as well as the ureters are not dilated no evident mass nor calculus in one scans obtained.

The urinary bladder is adequately distended showing regular contours and smooth walls. There are no abnormal intraluminal masses seen within.

The prostate gland measures 3.22 x 3.55 x 2.89 cm (IWT). It exhibits a homogenous parenchymal echopattern. Approximate weight 17 grams. No calcifications seen within.

Minimal to moderate amount of fluid collection is present within the abdomen.

37

Impression/Remarks: Consider liver cirrhosis correlation with the liver function tests suggested Minimal to moderate ascites Isoechoic renal parenchymal echopattern, bilateral cannot entirely rule out renal

parenchymal disease based on echogenicity. Serum creatinine correlation suggested

Sonographically normal gall bladder, biliary ducts, pancreas, urinary bladder and prostate glands

S/P splenectomy

38

IPD HEMATOLOGYDate: April 02, 2009 @ 09:32

Test Result Flag Limit Reference RangeWBC

- To determine infection or inflammation in the body and monitor its responses to specific therapies. Explain to the patient the necessity of undergoing the test that it helps detect occurrence of anemia and polycythemia.

15.0 (10E 9/L) H 4.6-10.2 (10E 9/L)

LYM

- to identify if there is an abnormal amount of lymphocyte that may indicate viral infection such as HIV. A decreased number of lymphocytes in the peripheral circulation, occurring as a primary hematologic disorder or in association with the nutritional deficiency, malignancy or infection mononucleosis.

4.8 (RM 32.1 %L) H 0.6-3.4 (10.0-50.0 %L)

MID 1.4 (9.2 %M) 0.0-1.8 (0.1-21.5 %M)GRAN

- An elevated level of granulocytes is indicative of an underlying bacterial infection.

8.8 (R4 58.7 %G H 2.0-6.9 (37.0-80.0 %G)

RBC

- to know the amount of RBC in the blood. Rule out anemia due to nutritional deficiencies,

3.15 (10E 12/L) L 4.69-6.13 (10E 12/L)

39

blood loss.HGB

-to identify the amount of O2 carrying protein contained within the RBC.

107 (g/L) L 141.0-181.0 (g/L)

HCT

- To identify the percentage of the blood volume occupied by red blood cells.- decreased hematocrit indicates blood los, anemia, blood replacement therapy, and fluid balance, and screens red blood cells status.

28.9 (%) L 43.5-53.7 (%)

MCV

- Mean corpuscular volume (MCV) is a measurement of the average size of your RBCs (red blood cells). The MCV is elevated when your RBCs are larger than normal (macrocytic), for example in anemia caused by vitamin B12 deficiency. When the MCV is decreased, your RBCs are smaller than normal (microcytic), such as is seen in iron deficiency anemia or thalassemias.

91.7 (fL) 80.0-97.0 (fL)

MCH

- Mean corpuscular hemoglobin (MCH) is a calculation of the average amount of

34.0 (pg) H 27.0-31.2 (pg)

40

oxygen-carrying hemoglobin inside a red blood cell. Macrocytic RBCs are large so tend to have a higher MCH, while microcytic red cells would have a lower value.

MCHC- Mean corpuscular hemoglobin concentration (MCHC) is a calculation of the average concentration of hemoglobin inside a red cell. Decreased MCHC values (hypochromia) are seen in conditions where the hemoglobin is abnormally diluted inside the red cells, such as in iron deficiency anemia and in thalassemia. Increased MCHC values (hyperchromia) are seen in conditions where the hemoglobin is abnormally concentrated inside the red cells, such as in burn patients and hereditary spherocytosis, a relatively rare congenital disorder.

370 (g/L) H 318-354 (g/L)

RDW

- Red cell distribution width (RDW) is a calculation of the variation in the size of your RBCs. In some anemias, such as pernicious anemia, the amount of variation (anisocytosis) in RBC size (along with

20.5 (%) H 11.6-14.8 (%)

41

variation in shape – poikilocytosis) causes an increase in the RDW.

PLT

- The platelet count is the number of platelets in a given volume of blood. Both increases and decreases can point to abnormal conditions of excess bleeding or clotting.

262 (10E 9/L) 142.0-424.0 (10E 9/L)

MPV

- Mean platelet volume (MPV) is a machine-calculated measurement of the average size of your platelets. New platelets are larger, and an increased MPV occurs when increased numbers of platelets are being produced. MPV gives your doctor information about platelet production in your bone marrow.

10.3 (fL) 0.0-99.8 (fL)

42

Clinical Chemistry

Patient name: Rambo Physician: Dr. Otero

Sex:M Age: 24 yrs old Analyzer: VITROS 250

Test initial date: April 02, 2009 Fluid: SERUM

Report print date: 04/02/09 Priority: Routine

TEST RESULT UNIT NORMAL RANGE

ALTthe most sensitive indicators of liver cell irritation or damage. The activity of this enzyme is measured in blood plasma. Elevated levels of this enzyme can be an indication of viral hepatitis and other forms of liver disease.

H 157 U/L 21 - 72

ALP

Alkaline phosphatase are a family of enzymes that are present throughout the body. Elevated levels of ALP are associated with liver and bile duct disorders, and bone diseases.

H 225 U/L 38 - 126

TOTAL PROTEIN

Measurement of the total protein concentration in plasma. Elevated concentrations reflect dehydration, which might be attributable to vomiting, diarrhea, Addison's disease, diabetic acidosis, and other conditions.

81 g/L 63 - 82

ALBUMIN L 21 g/L 35 - 50

43

Albumin is the most abundant protein found in blood plasma, representing 40 to 60% of the total protein. Reduced levels of albumin may reflect a variety of conditions, including primary liver disease, increased breakdown of macromolecules resulting from tissue damage or inflammation, malabsorption syndromes, malnutrition, and renal diseases.

GLOBULIN

Globulins are a diverse group of proteins in the blood, and together represent the second most common proteins in the bloodstream. An elevation in the level of serum globulin can indicate the presence of cirrhosis of the liver.

H 60 g/L 23 - 35

A/G RATIO L .4 1.5 - 2.5

TOTAL BILIRUBIN H 384.0 umol/L 3.0 – 22.0

Unconcentrated BILIRUBIN

H 31.1 umol/L 0.0 - 19.0

Direct BILIRUBIN H 352.9 umol/L 0.0 - 7.0

DATE: 04/02/09PROTHROMBIN TIMEPatient: 23.7 secondsControl: 13.5 secondsINR: 1.8% Activity: 57.0%

44

Clinical Microscopy

Name: T2 Date: April 15, 2009Age/ Sex: 24 M Hospital #: 1091204Requesting Physician: Dr. Florida Specimen: Urine

Findings:

A. Physical Examination: B. Chemical Reaction:Color: Dark yellow Albumin: negativeApperance: cloudy Sugar: negativeReaction: 6.0Specific Gravity: 1.010

C. Microscopic Examination:

Epithelial cells: Cast:Squamos: + Hyaline: _______/lpfRenal: ______/ lpf Fine Granular:_____/ lpfPus Cells: _____/ hpf Coarse granular:____/ lpfMusous Threads Crystal:Bacteria Uric AcidYeast cells Calcium OxalateOil globules UratesSpermatozoa Triple Phosphate

Amorphous PhosphateOthers

45

Lab no.: 11712

Name: T2 Age: 24 Sex: M Log#: 65592 Index date: .4/15/09Physician: Walk in Reference #: 59560 Print date: 04/15/09

Test Normal Value Result Units

Hepatitis above 2.0 considered 0.712 (NR) COIas reactive

Meds:

D5.3 NaCl FD 200 cc now then x8 hour

Essentiale forte 1 tab BID

Ranitidine 50 mg IVTT (NOW) then q 8 hour

Hyoscine amp 1 Amp(now) then q 8 hour

Metronidazole 500 mg q 8 hours

46

Generic Name: Essentiale Forte

Brand Name:

ClassificationsSuggested

DoseMode ofActions Indications

Contraindications

DrugInteractions

Side Effects/Adverse

ReactionsNursing

Responsibilities- Cholagogues,

Cholelitholytics

& Hepatic

Protectors

-Essentiale 1-2

cap tds.

Essentiale

Forte Intiailly 2

cap tds.

Maintenance: 2

cap once-bd.

- increase

functional

status of the

liver,

improvemen

t in the

lipids

metabolism

caused by

accelerated

synthesis of

lipoproteins

in the liver,

activation of

the

phospholipi

d-depending

ferments,

- cirrhosis

- Hepatic

steatosis

(also in cases

of diabetes)

- Acute and

chronic

hepatitis

- Necrosis of

the liver cells

- Hepatic

coma and

precoma

- Toxic liver

damage

(including

- Contraindicated

in patients

hypersensitive to

drug

-in newborn

children

-in pregnant

women

Drug-drug. abdominal

pain, nausea,

diarrhea and

allergic

reaction(skin

rash).

1. Instruct patient on

proper use of the drug

2. Urge patient to avoid

cigarette smoking because

this may increase gastric

acid secretion and worsen

disease

3. Inform patient to take

drug once daily

prescription at bedtime for

best results.

4. Tell the physician what

medicines you are taking,

including those bought

without a prescription and

herbal medicines, before

you start treatment with

47

increased

synthesis of

glycogen in

the liver,

decreased

the fatty

infiltration

of the

hepatocytes

pregnancy

toxicosis)

-

Essentiale.

5. Tell the physician

before taking any new

medication while taking

this one, to ensure that the

combination is safe.

6. Do not use the medicine

for other health

conditions.

http://en.wikipedia.org/wiki/Essentiale, http://www.drugs-pro.com/liver-disease/essentiale%20forte.html

Generic Name: hyoscine butylbromide Brand Name: Buscopan

Suggested Mode of Contra DrugSide Effects/

Adverse Nursing

48

Classifications Dose Actions Indications

indications Interactions Reactions Responsibilities

- antispasmodic - 0.4 to 0.8 mg P.O.

daily

- used to

relieve

bladder or

intestinal

spasms.

-relaxing the

muscle that

is found in

the walls of

the stomach,

intestines

and bile

duct

(gastrointest

inal tract)

and the

reproductive

organs and

urinary tract

(genitourina

ry tract)

-Spasms

of the

stomach,

intestines

or bile

duct

(gastrointe

stinal

tract),

including

those

associated

with

irritable

bowel

syndrome

)

-Spasms

of the

reproducti

ve or

-

Hypersensitivi

ty

-Abnormal

muscle

weakness

(myasthenia

gravis).

-Abnormally

large or

dilated large

intestine

(megacolon).

-Hereditary

blood

disorders

known as

porphyrias.

-Closed angle

glaucoma.

-Buscopan

Drug-drug. Antidepressants, antihistamines, disopyramide, quinidine: additive anticholinergic effects

Antidepressants, antihistamines, opioid analgesics, sedative-hypnotics: additive CNS depression

Oral drugs: altered absorption of these drugs

Wax-matrix potassium tablets: increased GI mucosal lesions

Drug-herbs. Angel's trumpet, jimsonweed, scopolia: increased

Adverse reactions

CNS: drowsiness, dizziness, confusion, restlessness, fatigue

CV: tachycardia, palpitations, hypotension, transient heart rate changes

EENT: blurred vision, mydriasis, photophobia, conjunctivitis

GI: constipation, dry mouth

GU: urinary hesitancy or

1.Assess vital signs and

neurologic,

cardiovascular, and

respiratory status.

2.Monitor patient for

urinary hesitancy or

retention.

3.Swallow tablets whole

with a glass of water.

Take at least one hour

before antacids or certain

anti-diarrhea drugs.

4. Do not share this

medication with others.

3. Inform your doctor or

pharmacist if you have

previously experienced

such an allergy. If you

feel you have

experienced an allergic

reaction, stop using this

49

urinary

systems

(genitouri

nary

tract), for

example

period

pain

cramps.

tablets are not

recommended

for children

under six

years of age.

anticholinergic effects

Drug-behaviors. Alcohol use: increased CNS depression

retention

Skin: decreased sweating, rash

medicine.

4. Tell your doctor or

pharmacist what

medicines you are

already taking, including

those bought without a

prescription and herbal

medicines, before you

start treatment with this

medicine.

5. This medicine should

be used with caution

during pregnancy, and

only if the expected

benefit to the mother is

greater than the possible

risk to the fetus,

particularly in the first

trimester. Seek medical

advice from your doctor.

6. It is not known if this

medicine passes into

50

breast milk. It should be

used with caution in

nursing mothers, and

only if the benefits to the

mother outweigh any

risks to the nursing

infant.

7. This medicine may

cause blurred vision and

so may affect your ability

to drive or operate

machinery safely. If

affected do not drive or

operate machinery.

http://www.medicinenet.com/hyoscine_butylbromide-oral/article.htm, http://medical-dictionary.thefreedictionary.com/hyoscine

ClassificationsSuggested

DoseMode ofActions Indications

Contraindications

DrugInteractions

Side Effects/Adverse

ReactionsNursing

ResponsibilitiesAnti-infectives,

antiprotozoals,

1 amp q 8° Disrupts

DNA and

PO, IV:

Treatment

Contraindicated

in:

Drug-drug:

Cimetidine may

CNS:

Seizures, 1. Adiminister on empty

51

Generic Name: Metronidazole

Brand Name: Flagyl

antiulcer agents protein

synthesis

susceptible

organisms.

Therapeutic

effects:

Bactericidal,

trichomonaci

dal or

amebicidal

action.

Spectrum:

Most notable

for avtivity

against

anaerobic

bacteria

including:

Bacteroides,

clostridium.

In addition is

active

of the

following

anaerobic

infections:

Intra-

abdominal

infections,

gynecologic

infections,

skin and

skin

structure

infections

lower

respiratory

tract

infections,

CNS

infections,

septicemia,

and

endocarditis

Hypersensitivit

y.

Use cautiously

in: history in

blood

dyscrasias,

History of

seizures or

neurologic

problems and

severe hepatic

impairement.

decrease

metabolism of

metronidazole.

Phenobarbital and

rifampin

increases

metabolism and

may decrease

effectiveness.

Metronidazole

increases the

effects of

phenytoin,

lithium, and

warfarin.

Disulfiram-like

reaction may

occur with

alcohol ingestion.

May cause acute

psychosis and

confusion with

dizziness,

headache.

EENT:

Tearing

(topical only).

GI:

Abdominal

pain,

anorexia,

nausea,

diarrhea, dry

mouth, furry

tongue,

glossitis,

unpleasant

taste and

vomiting.

Hemat:

Leukopenia

Neuro:

Peripheral

neuropathy

stomach or may

administer with food or

milk to minimize GI

irritation.

2.Instruct patient to take

medication exactly as

directed with evenly

spaced times between

doses, even if feeling

better.

3.Advised patient to not

skip doses or double up

on missed doses.

4.Inform patient that

medication can cause

metallic taste.

5.Advise patient that

frequent mouth rinses,

good oral hygiene and

sugarless gum or candy

may minimize dry

mouth.

52

against:

Trichomonas

vaginalis,

entamoeba

histolytica,

giardia

lamdia, H.

pylori and

clostridium

difficile.

.

IV:

Perioperativ

e

prophylacti

c agent in

colorectal

surgery.

PO:

Amebecide

in the

managemen

t of amebic

dysentery,

amebic

liver

abscess and

trichomonia

sis:

treatment of

peptic ulcer

disease

disulfiram.

Increased risk of

leucopenia with

fluorourousel or

azathioprine.

6.Inform patient that

medication may cause

urine to turn dark.

7.Advise patient to

consult health care

professional if no

improvement in a few

days or if signs and

symptoms of

superinfection (black

furry overgrowth on

tongue or foul-smelling

stools) develop.

53

caused by

Helicobacte

r pylori.

ClassificationsSuggested

DoseMode ofActions Indications

Contraindications

DrugInteractions

Side Effects/Adverse

ReactionsNursing

ResponsibilitiesTherapeutic:

Antiulcer agents

Pharmacologic:

Histamine H2

antagonist

50 mg IVTT

now q 8°

Inhibits the

action of

histamine at

the H2-

receptor site

located

primarily in

Short term

treatment of

active

duodenal

ulcers and

benign

gastric

Contraindicated

in:

Hypersensitivit

y. Cross

sensitivity may

occur. Some

products

Drug-drug:

Cimetidine

inhibits drug

metabolizing

enzymes in the

liver; may lead to

increase levels

CNS:

confusion,

dizziness,

drowsiness,

hallucinations

, headache.

CV:

1. Assess for

epigastric or

abdominal pain

and frank or

occult blood in

the stool, emesis

or gastric

54

Generic Name: Ranitidine Bismuth CitrateBrand Name: Tritec

gastric

parietal

cells,

resulting in

inhibition of

gastric acid

secretion. In

addition,rani

tidine

bismuth

citrate has

some

antibacterial

action

against H.

Pylori.

Therapeutic

effects:

Healing and

prevention

of ulcers.

Decrease

ulcers.

Prophylaxis

of duodenal

ulcers (at

lower

doses).

Manageme

nt GERD

treatment

and

prevention

of

heartburn,

acid

indigestion

and sour

stomach

(OTC use).

Cimetidine,

famotidine,

ranitidine:

managemen

contained

alcohol and

should be

avoided in

patients with

known

intolerance.

Porphyria

(ranitidine

bimuth citrate

only). Some

products

contain

aspartame and

should be

avoided in

patients with

phenylketonuria

.

Use cautiously

in: Renal

impairement.

and toxicity in the

following- some

benzodiazepines,

beta blockers,

caffeine, calcium

channel blockers,

carbamazepine,

chloroquine,

lidocaine,

metronidazole,

moricizine,valpor

ic acid and

warfarin.

arrythmias

GI: Altered

taste, black

tongue,consti

pation, dark

stools,diarrhe

a and drug-

induced

hepatitis,

nausea.

GU:

Decreased

sperm count,

impotence.

Hemat:

Agranulocyto

sis, aplastic

anemia,

anemia,

neutropemnia,

thrombocytop

enia.

aspirate.

2. Administer with

meals or

immediate

afterward and at

bedtime to

prolong effect.

3. Doses administer

once daily at

bedtime to

prolong effect.

4. Instruct patient to

take medication

as directed for the

full course of

therapy, even if

feeling better.

5. Inform patient

that increased

fluid and fiber

intake and

exercise may

55

symptoms of

gastroesopha

geal reflux.

Decreased

secretion of

gastric acid.

t of gastric

hypersecret

ory states

(Zollinger-

Ellison

syndrome).

Unlabeled

uses:

Manageme

nt of GI

symptoms

associated

with the use

of NSAIDs.

Prevention

of stress

ulceration

or

aspiration

pneumoniti

s.

Prevention

Misc:

Hypersensitivi

ty reactions,

vaculitis

minimize

constipation.

6. Advise patient to

report onset of

fever, sorethroat,

diarrhea,

dizziness, rash,

confusion, or

hallucinations.

7. Inform patient

that medication

may temporarily

cause stools and

tongue to appear

gray-lack.

56

of acid

inactivation

of

supplement

al

pancreatic

enzymes in

patients

with

pancreatic

insufficienc

y.

57

Nursing Theories

Theorist: Faye Glenn Abdella

Theory: 21 Nursing Problems

Abdellah's theory of nursing stated that it was the “determination of the nature and extent

of nursing problem presented by the individual patients or families receiving nursing care”. She

says a nursing problem presented by a client is a condition faced by the client or client's family

that the nurse, through the performance of professional functions, can assist them to meet.

Abdellah's use of term “nursing problems” is more consistent with nursing functions or nursing

goals than with those client-centered problems. The apparent contradiction can be explained by

her desire to move away from the disease-centered orientation. In her attempt to bring nursing

practice into its proper relationship with restorative and preventive measures for meeting total

client needs, her model seems to swing the pendulum to the opposite pole, from the disease

orientation to nursing orientation, while leaving the client somewhere in the middle.

The student nurses are instruments by which certain nursing problems which are faced

by the client and the client's family are addressed and met. Quality professional nursing care

requires the nurses to identify and solve overt and covert nursing problems. This theory

emphasizes a client-centered approach because it is the primary role of the nurse to alleviate the

patient from whatever suffering she is in and help her meet her needs. Her framework is efficient

enough to address and meet the different requirements of the three major aspects of her

“pendulum model” which consists of client-oriented, nursing-centered and disease-centered

approach.

58

Theorist: Lydia Hall

Theory: Core, Care and Cure Theory

Hall's theory emphasizes the importance of individuals as unique, capable of growth and

learning, and requiring a total person approach. Her definition of health can be inferred to a state

of self-awareness with conscious selection of behaviors that are optimal for that individual. Hall

stresses the need to help the person explore the meaning of his or her behavior to identify and

overcome problems through developing self-identity and maturity. The concept of society or

environment is dealt with in relation to the individual. Hall's theory of nursing involves three

interlocking circles, each one of it represents one aspect of nursing. The same aspect represents

intimate bodily care of the patient. The core aspect deals with the innermost feeling and

motivations of the patient and family through the medical aspects of care.

Care is the sole function of nurses, where as core and cure are shared with other

members of the health care team. The major purpose of care is to achieve interpersonal

relationship with the individual. The nurse plans and prepares a series of independent nursing

interventions that can aid from its condition. These interventions are designed to provide good

and conducive atmosphere, administering drugs to the right patient, right drug and right time.

The nurse also provides health teachings to his client who it can be based on medication

management and independent actions such as advising the client to have complete bed rest.

59

Theorist: Ida Jean Orlando

Theory: Nursing Process Theory

Orlando’s theory was developed in the late 1950s from observations she recorded

between a nurse and patient. Despite her efforts she was able to categorize the records as “good”

or “bad” nursing. It then dawned on her that both formulations of “good” and “bad” nursing were

contained in the records. From these observations she formulated the deliberative nursing

process. The role of the nurse is to find out and meet the patient’s immediate needs for help. The

patient’s presenting behavior maybe a plea for help, however, the help needed may not be what it

appears to be. Therefore, nurses need to use their perception, thoughts about the perception or the

feelings engendered from their thoughts to explore with patients the meaning of their behavior.

This process helps the nurse finds out the nature of the distress and what help the patient needs.

Orlando ’s theory remains one of the most effective practice theories available. The use of her

theory keeps the nurses to focus on their patients. The strength of the theory is that it is clear,

concise and easy to use. While providing the overall framework for nursing, the use of her theory

does not exclude nurses from using other theories while caring for the patient.

Student nurse is finding out the problem and meeting the patient’s immediate needs. This

is possible due to the fact that the nurse seeks out the nature of the problems using her perception

based on her cognitive and motor skills thus having a better understanding of how to address the

needs of the patient with the east possible effort alongside with the greatest and maximal result

and efficiency. The theory is presented with fewer complications thus time and energy is

conserved. This provides the nurse to have more time to focus more on her patient and this

serves as an opportunity to furthermore look for underlying complaints and problems.

60

Date / Time

Cues Needs Nursing Diagnosisw/ Rationale

Objective of Care

Nursing Interventionw/ Rationale

Evaluation

April 17, 2009

4:00pm

Subjective:

“Dugay-dugay na ang sakit sa akoang tiyan.”“Murag naa’y hangin.”“4.” [pain scale: 0=none;1-3=mild;4-6=moderate;7-10=severe]

Objective:

-occasional guarding behavior toward the abdominal area noted.-mild grimacing noted.

Vital Signs:

BP- 110/60 mmHg

PR- 78 bpm

RR- 24 bpm

TEMP. - 37.6 °C

COGNITIVE-PERCEPTUAL

PATTERN

Acute pain [abdominal] related to flatulence secondary to increase in gastrointestinal motility.

R: Increased gastrointestinal motility increases the amount of abdominal gas which exerts pressure on the gastrointestinal tract walls resulting in pain.

Source: Marilynn E. Doenges, APRN, BC, et. al. Nurse’s Pocket Guide, 10th ed. © 2006. F.A. Davis Company, Philadelphia, Pennsylvania

Within the remaining 7 hours of our shift, the patient will be able to experience less pain as evidenced by verbalization of decreased pain [pain scale < 4] and less guarding behavior toward the abdomen.

1.) Perform pain assessment each time pain occurs; Note and compare previous reports.

®To identify possible factors that worsen the pain; to help out

in further pain control. 2.) Monitor vital signs.

®Usually elevated during occurences of pain.

3.) Instruct patient to report pain as soon as it occurs.®For non-delayed interventions

to be performed.4.) Provide non-pharmacological pain management such as therapeutic touch®To promote cost-free comfort

5.) Identify ways to alleviate/minimize pain®To promote independent self-

care6.) Note specific time and activity when pain occurs.®To administer medications as

prophylaxis appropriately.7.) Review ways to minimize pain regularly

®To maintain and promote ability to care for self

8.) Obtain laboratory results

Goal Met:

Patient was able to experience less pain, as evidenced by verbalization of a pain scale of 1 and lessened guarding behavior toward the abdomen.

61

from laboratory technician®To determine possible causes

of pain in the abdomen.9.) Assist in treating AGE®To treat the underlying cause

of the pain.10.) Educate watcher(s) on how they can help alleviate the pain.®For continuous cost-free pain

management.11.) Administer analgesics as ordered.

®Medications that are ordered for pain will greatly help in

alleviating pain.12.) Administer oxygen as ordered.

®Oxygen therapy can help alleviate pain.

Date / Time

Cues Needs Nursing Diagnosisw/ Rationale

Objective of Care

Nursing Interventionw/ Rationale

Evaluation

62

April 17, 2009

4:00pm

Subjective:

“Gina-uhaw ko pirminti”“Mga unom ka beses na ko sige ug balik-balik sa CR.”“Basa akong mga tae.”

Objective:

-ectomorphic body structure-imbalanced intake and output [output is greater than intake]

Vital Signs:BP- 110/60

mmHg

PR- 78 bpm

RR- 24 bpm

TEMP. - 37.6

NUTRITIONAL-

METABOLIC

PATTERN

Deficient fluid volume related to excessive fluid loss secondary to increased peristaltic movement in the gastrointestinal tract

R: Increased peristaltic movement in the gastrointestinal tract overwhelms the large intestine and hinders it from absorbing much needed water, causing excessive amounts of fluid to be lost through the stool

Source: Marilynn E. Doenges, APRN, BC, et. al. Nurse’s Pocket Guide, 10th ed. © 2006. F.A. Davis Company, Philadelphia, Pennsylvania

Within our remaining 7 hours span of care, patient will be able to perform activities and self-treatments for correction of deficient fluid volume and show fluid intake grater than output.

1.) Assess level of understanding®Helps out in determining how to

proceed with patient education and instruction.

2.) Monitor Vital Signs; note strength of peripheral pulses.

®Deficient fluid volume results in poor perfusion; perfusion can be

assessed by strength of pulse.3.) Establish 24-hour fluid replacement needs and routes to be used

®Prevents peaks/valleys in fluid level4.) Note client’s preferences regarding food and fluids that have high fluid content

®Prevents refusal in offered food and drinks

5.) Keep fluids within arms reach®Promotes independent self-care

6.) Encourage to increase oral fluid intake

®Increases hydration rate7.) Provide adequate hygiene to entire body, especially the eyes and mouth.

®Prevents damage from dryness8.) Weigh patient daily® indicates overall fluid and nutritional status

9.) Administer intravenous fluids as ordered.

®Increases hydration rate10.) Educate watchers on how to

Goal Met:

Patient was able to increase oral fluid intake and was able to show fluid intake being greater than fluid output.

63

°C monitor intake and output.®Promotes continuous care.

11.) Administer medications as prescribed.

®Proper medication will ensure good recovery.

12.) Give Oral Rehydration Solution, if not contraindicated.

®Helps out in replacing lost fluids

Date / Time

Cues Needs Nursing Diagnosisw/ Rationale

Objective of Care

Nursing Interventionw/ Rationale

Evaluation

64

April 17, 2009

4:00pm

Subjective

“Mga unom ka beses na ko sige ug balik-balik sa CR.”“Basa akong mga tae.”

Objective-decreased level of sodium

Vital Signs:

BP- 110/60

mmHg

PR- 78 bpm

RR- 24 bpm

TEMP. - 37.6

°C

NUTRITIONAL-

METABOLIC

PATTERN

Imbalanced nutrition: less than body requirements related to inability to absorb nutrients secondary to increased peristalsis of gastrointestinal tract

R: Increased peristalsis of the gastrointestinal tract hinders the small intestine to absorb much needed nutrients resulting in decreased nutrition.

Source: Marilynn E. Doenges, APRN, BC, et. al. Nurse’s Pocket Guide, 10th ed. © 2006. F.A. Davis Company, Philadelphia, Pennsylvania

Within our remaining 7 hours span of care, our patient will be able to maintain or develop current nutritional status by increasing oral food intake and showing increased appetite.

1.) Determine ability to chew, swallow and taste.

®Ensures success in future interventions

2.) Discuss eating habits, food preferences, allergies and dislikes

®To appeal to preference and to prevent ingestion of non-preferred

food/fluid.3.) Assess weight, body build, strength and activity level.

®Provides a baseline data for comparison.

4.) Encourage to have of food and fluids rich in nutrients like preferred and non-preferred fruits and vegetables.

®Presents a wide-range of food for variety

5.) Use flavoring agents (e.g., lemon, herbs, salt)

®Enhances appetite; promotes intake of food

6.) Limit fiber/bulk food and carbonated beverages

®May lead to early satiety7.) Encourage to restrict self from unpleasant sights or odors

®May decrease appetite8.) Consult dietitian/nutritional advisor as indicated.

®Promotes further wellness and nutrition

Goal Met:

Patient was able to increase oral food intake with good over-all appetite.

65

9.) Obtain repeated laboratory results from laboratory technician

®To determine effectiveness of diet therapy

10.)Educate watcher(s) to watch out for factors that induce vomiting and/or regurgitation of food

®Ensures prevention of future complications

11.) Administer medications as ordered

®Medications ensure good over-all recovery

12.) Monitor Intake and Output as ordered.® To determine water retention.

Date / Time

Cues Needs Nursing Diagnosisw/ Rationale

Objective of Care

Nursing Interventionw/ Rationale

Evaluation

66

April 17, 2009

4:00pm

Subjective

“Gitanggal akoang spleen katong ni-aging 2005”“Nadiagnose ko ug liver cirrhosis katong 2006.”

Objective

-status: post splenectomy-Admitting diagnosis: “Liver cirrhosis…”-location: DMC Communicable Pavillion

Vital Signs:

BP- 110/60

HEALTH

PERCEPTION

–

HEALTH

MANA

Risk for infection related to decreased immune system efficiency 2° post splenectomy and liver cirrhosis.

R: Complications with the liver and spleen decrease the body’s capability to maintain an optimal defense against infectious bacteria

Source: Marilynn E. Doenges, APRN, BC, et. al. Nurse’s Pocket Guide, 10th ed. © 2006. F.A. Davis Company, Philadelphia, Pennsylvania

Within our remaining 7 hours span of care, our patient will be able to have a decreased risk of infection as evidenced by a clean environment, hygienic practices, and general asepsis.

1.) Stress proper hand washing to all individuals involved in patient’s care

®Ensures control of the spread of bacteria and prevention of

nosocomial infections 2.) Monitor care givers and watchers

®To ensure patient will remain free from contact with suspected bacteria-

filled surfaces3.) Provide frequent proper general and oral hygiene

®Reduces surfaces having multiplying bacteria

4.) Instruct not to wander around too much or too far

®May lead to contact with bacteria-filled surface

5.) Explain importance of wearing face mask

®Face masks are effective in preventing infection by air-borne

bacteria6.)Provide isolation as indicated

®Prevents cross contamination7.) Emphasize necessity of taking antibiotics as directed

®Premature discontinuation of treatment may lead to an infection

8.) Occasionally obtain clean linens for the patient to change into

®Linens may serve to be a good place for bacteria to proliferate

9.) Advise watchers to change unable

Goal Met:

Patient was able to have a clean environment, good hygienic practices, and over-all bacteria free surfaces.

67

mmHg

PR- 78 bpm

RR- 24 bpm

TEMP. - 37.6

°C

GEMENT

PATTERN

person to change clothes®Clothes can be a place for bacteria

to reside10.)Educate watchers on how to identify infections

®Ensures immediate care to be gathersd

11.) Administer antibiotics as ordered®Antibiotics serve as prophylaxis

12.) Monitor intake and output as ordered® to determine water retention.

Date / Time

Cues Needs Nursing Diagnosisw/ Rationale

Objective of Care

Nursing Interventionw/ Rationale

Evaluation

68

April 17, 2009

4:00pm

S/O:- with

jaundice noted in the skin upon inspection.

- (+)body malaise

- sunken eyeballs

- dry lips

Vital Signs:BP- 110/60

mmHg

PR- 78 bpm

RR- 24 bpm

TEMP. -

37.6 °C

NUTRITIONAL

METABOLIC

PATTERN

Risk for impaired skin integrity r/t accumulation of bile salts in skin secondary to Liver Cirrhosis.

R: At risk for skin being adversely altered.

Source: Marilynn E. Doenges, APRN, BC, et. al. Nurse’s Pocket Guide, 10th ed. © 2006. F.A. Davis Company, Philadelphia, Pennsylvania

Within our 8 hours span of care, our patient will be able to:Demonstrate behaviors/ techniques to prevent skin breakdown.

1.) VS checked and recorded.® to have a baseline data.2.) Check and regulate IVF @ ordered rate.® to prevent further dehydration.3.) Assess for any changes in skin.® to determine the causative factors4. Encourage continuation of regular exercise.®: to enhance circulation.5.) Maintain strict skin hygiene.® to prevent the spread of bacteria and prevent infection6.) Provide adequate clothing/covers.®to prevent vasoconstriction.7.) Observe for reddened/blanched areas and institute treatment immediately.®: Reduces likelihood of progression to skin breakdown.8.) Emphasize importance of adequate nutritional/fluid intake.®: to maintain general good health and skin turgor.9.) Note laboratory results pertinent to causative factors.® to determine the needed treatment to

be given.10.) Assist the client in understanding and following medical regimen and preventive care and daily maintenance.®: Enhances commitment to plan, optimizing outcomes.

Goal Met:

Patient was able to demonstrate behaviors and techniques that prevents skin breakdownlike skin care, proper nutrition intake, exercise and comply with medications.

69

11.) Administer medications as ordered.® to treat any underlying cause 12.) Monitor intake and output as ordered® to determine fluid and electrolyte intake and loses

70

Discharge Plan

MEDICATION

Instruct the patient and family to follow the home medications as prescribed by the

physician.

R: Treatment regimen is important to have faster recovery.

Explain each purpose of the medication

R: Knowledge about what medications will make the client become aware of what he is

taking and for the family to participate more in the client’s treatment.

Instruct client not to take over-the-counter drugs without doctor’s knowledge.

R: Non-prescribed drugs may have an antagonistic effect or synergistic effect in any

drug therapy.

Explain the side effects or adverse reactions of each medication. Instruct the client and

family to watch out for it and to report it immediately as soon as possible to the

physician.

R: Explaining the side effects will let the client and family identify what harmful effects

to expect and for them to distinguish the adverse reaction to medication for them to report

it to their physician immediately.

Inculcate to the client to comply all the medications prescribed at the ordered dosage,

route and at the ordered time.

R: Taking the drugs at the ordered dose, route and time limits the chance for toxicity and

ensure its effectiveness.

71

Advice client to take medications with food if not contraindicated or to take medicine one

hour before meals or one hour after meals.

R: Some medications are irritating to the gastric mucosa.

Let patient complete the whole course of the drug therapy.

R: This can help the patient alleviate the problem and be able to experience the full

therapeutic effect of the medication.

EXERCISE

Encourage early ambulation.

R: Walking is good exercise and could promote circulation, hence, proper healing.

Promote exercise to the client especially ROM.

R: This will promote good physical health.

Instruct client to avoid strenuous activities for at least a week or a month until fully

recovered.

R: Activities that require great muscle strength should be avoided to prevent injury and

muscle strain.

Advise patient to have adequate rest and sleep.

R: To gain back the lost strength and be able to return to its normal state thus allow ample

time for healing.

Practice deep breathing exercise.

R: This will help alleviate any pain or discomfort that patient will encounter

72

TREATMENT

Explain the need of treatment after discharge and must take it seriously so as to prevent

such complications to the patient

R: To make the client and family aware that the treatment does not only end at hospital but

needs to be continued at home to make the client responsible towards medication.

Explain to the family the condition of the patient and give them factual information about

the illness.

R: To have better understanding of the patient’s condition and to be able to know what

intervention they should give that could not alter the effect of the therapy.

HYGIENE

Encourage having proper hygiene like taking a bath, meticulous hand washing, and

brushing of teeth every after meal.

R: Hygiene promotes comfort and cleanliness to the patient. It also increases the sense of

wellness, which is very much needed in the therapeutic process.

Encourage patient to continue hygienic measures practiced at present such as changing

clothes everyday and changing of underwear as often as necessary, keeping the nails

neatly trimmed, maintaining own supplies/items for personal necessities.

R: Keeping all practiced measures is necessary in consistent maintenance of proper hygiene.

Owning personal accessories for hygiene purposes keep client away from contamination and

infectious diseases.

Provide a calm, clean, and accepting environment.

73

R: Calm, clean and non threatening environment may lessen the occurrence of possible

infection and would be a good place for healing.

OUTPATIENT ORDER

Inform the patient that follow-up check-up is important to have continuous monitoring

and care even after attainment of the course medical therapy.

R: Through constant visits as out patient, the physician would still monitor the progress of

the therapeutic intervention availed by the patient.

Advice the client and the family to carry out follow-up diagnostic examinations

R: This is to evaluate the therapeutic response of the patient to the treatment.

Instruct the family to report any unusual signs and symptoms experienced by the patient.

R: This will help detect early signs and symptoms of recurrence of the disease.

DIET

Encourage client to eat a variety of nutritious foods like fruits and vegetables once

instructed by the physician.

R: To maintain and promote a healthy body.

Instruct client to take vitamins as ordered.

R: To boost the body’s defense mechanism.

Encourage patient to increase oral fluid intake.

R: This hydrates the body for normal functioning and maintain acid-base balance.

Advise client not to skip meals and have a regular eating pattern/schedule.

R: Regular interval of meals is the basic principle of a good dietary plan.

74

Tell patient not to eat foods contraindicated by the physician.

R: To prevent the occurrence of complications.

Instruct patient to avoid drinking liquors and smoking

R: To also avoid illness to be triggered.

75

Prognosis

CategoryPoor

(1)

Fair

(2)

Good

(3)Justification

1. Duration

of Illness

It has been one month since he

has been having diarrhea.

2. Onset of

Illness

Getting infected and contracting

AGE could have been avoided by

good hygiene.

3.

Predisposing

Factors

Race and location predispose T2

to getting AGE

4.

Precipitating

Factors

2 out of 5 precipitating factors are

present. However, these factors

could have been avoided by very

simple hygiene and prevention

methods.

5.

Willingness

to take the

medications

or

compliance

to treatment

regimen

T2 is very willing to take his

medications. He knows the good

effects of the drug and

intravenous therapy.

6.

environment

T2 was admitted to the

Communicable Pavilion in DMC.

76

7. family

support

The most number of family

members that were present in the

ward was 5. This number included

every member of his immediate

family except the father.

Calculation

s

4x1 =

4

1x2 =

22x3 = 6

4 + 2 + 6 = 12

12/7 = 1.7

Ranges:

1.0 – 1.5 = Poor

1.5 – 2.5 Fair

2.5 – 3.0 = Good

T2 has a FAIR prognosis.

His condition has been with him for about a month before he chose to seek treatment. He

took for granted the worsening of his condition. He could have possibly prevented the

complications brought about by his condition if he had only consulted a health care professional

immediately. Also, simple observance of good hygiene could have been a means to prevent him

from contracting the infection of AGE. On the other hand, upon seeking medical care, his family

support and good compliance of medicines were observed. Through this, our prognosis has come

up to the fair category.

77

Recommendation

To the Student Nurses:

We have also evaluated ourselves and have agreed that we have to heed the

recommendations of our clinical instructor. Patient care is our ultimate goal and continuous

monitoring and application of nursing interventions is compulsory for the patient’s recovery.

Data gathering skills should also be honed for accurate presentation of cases.

To the Patient and his family:

Religious taking of medicine was promoted as well as good general and oral hygiene.

Good family support can boost the morale of the patient and continuous holistic care will

improved his over-all health. He must also accept his condition and be aware of it, so that he

could disciplined himself and follow the necessary interventions given.

To the Ateneo de Davao University – College of Nursing

The group is proud to belong to such a prestigious school. We recommend that the

Ateneo de Davao University’s College of Nursing keep up, or improve their inculcation of

morals and values to their student nurses. Aside from that, continuous teaching and evaluating

our skills will lead us to aim a higher standard of education.

78

To the readers:

The group recommends that you, the reader, broaden your knowledge and continue

reading other sources and not base anything on this case presentation alone. A variety of sources

make a good over-all understanding of a subject.

Liver Cirrhosis is not always preventable for those at risk, however, steps can be taken to

lower the chance to develop and to delay the possible outcome. That’s why we recommend that

everybody must take care of themselves in preparing or eating foods. They must also establish

new patterns of eating, drinking, and lifestyle in order to prevent diseases from occurring.

79