Transcript
A CASE STUDY FOR HEPATIC ABSCESS
A Case Study Presented to the Faculty Of the College of Nursing Capitol University, CDOC
In Partial Fulfillment of the Subject: RLE 7
By: Abada, Joana Marie Z. Sogoc, Windel A. Soon, Richelle Anne B. Sosmeña, Vannessa M. Sugarol, Kristine Mae U. Sunico, Kennelyn A. Sumile, April Rose G. Supangan, Dan A. Supnet, Eden Rhea J. Tabasan, Robert Y. Tadlas, Bonimar R. Taganas, Ronna Marie R.
Submitted to:
Rick Wilson Bunao, RN Clinical Instructor
January 2010
Intr troduction The liver is subject to a variety of disorders and diseases. One is Abscesses which is caused by acute appendicitis; appendicitis ; those occurring in the bile ducts may result from gallstones gallstone s or may follow surgery. The parasite that causes amebic dysentery in the tropic tropics s can can produ produce ce liver liver absces abscesse ses s as well. well. Vario Various us othe otherr paras parasite ites s prev prevale alent nt in different parts of the world also infect the liver. Certain drugs may also damage the liver, producing jaundice. A common sign of impaired liver function is jaundice, jaundice , a yellowness yellowness of the eyes and skin arising from excessive bilirubin in the blood. Jaundice can result from an abnormally high high leve levell of red red blood blood cell cell destruct destruction ion (hemoly (hemolytic tic jaundice jaundice), ), defecti defective ve uptake uptake or transport of bilirubin by the hepatic cells (hepatocellular jaundice), or a blockage in the bile duct system (obstructive jaundice). Failure of hepatic cells to function can result from hepatitis, hepatitis , cirrhosis, cirrhosis, tumors, vascula vascularr obstruct obstruction, ion, or poisoni poisoning. ng. Symptom Symptoms s may includ include e weakn weaknes ess, s, low low bloo blood d press pressure ure,, easy easy bruisi bruising ng and and bleedi bleeding ng,, tremo tremor, r, and accum accumul ulati ation on of fluid fluid in the the abdo abdome men. n. Blood Blood tests tests can can reve reveal al abno abnorm rmal al leve levels ls of bilirubin, cholesterol, serum proteins, urea, ammonia, and various enzymes. A specific diagnosis of a liver problem can be established by performing a needle biopsy. Bacterial abscess of the liver is relatively rare. It has been described since the time of Hippocrates (400 BC), with the first published review by Bright appearing in 1936. In 1938, Ochsner's classic review heralded surgical drainage as the definitive therapy; howe however ver,, despi despite te the the more more aggre aggressi ssive ve appr approa oach ch to treatm treatment ent,, the the mort mortali ality ty rate rate remained at 60-80%. The develop developmen mentt of new radiolo radiologic gic techniq techniques, ues, the improve improvemen mentt in microbi microbiolog ologic ic ident identifi ificat cation ion,, and and the advan advancem cemen entt of draina drainage ge techn techniqu iques, es, as well well as impro improved ved supportive care, have decreased mortality rates to 5-30%; yet, the prevalence of liver abscess has remained relatively unchanged. Untreated, this infection remains uniformly fatal.
Intr troduction The liver is subject to a variety of disorders and diseases. One is Abscesses which is caused by acute appendicitis; appendicitis ; those occurring in the bile ducts may result from gallstones gallstone s or may follow surgery. The parasite that causes amebic dysentery in the tropic tropics s can can produ produce ce liver liver absces abscesse ses s as well. well. Vario Various us othe otherr paras parasite ites s prev prevale alent nt in different parts of the world also infect the liver. Certain drugs may also damage the liver, producing jaundice. A common sign of impaired liver function is jaundice, jaundice , a yellowness yellowness of the eyes and skin arising from excessive bilirubin in the blood. Jaundice can result from an abnormally high high leve levell of red red blood blood cell cell destruct destruction ion (hemoly (hemolytic tic jaundice jaundice), ), defecti defective ve uptake uptake or transport of bilirubin by the hepatic cells (hepatocellular jaundice), or a blockage in the bile duct system (obstructive jaundice). Failure of hepatic cells to function can result from hepatitis, hepatitis , cirrhosis, cirrhosis, tumors, vascula vascularr obstruct obstruction, ion, or poisoni poisoning. ng. Symptom Symptoms s may includ include e weakn weaknes ess, s, low low bloo blood d press pressure ure,, easy easy bruisi bruising ng and and bleedi bleeding ng,, tremo tremor, r, and accum accumul ulati ation on of fluid fluid in the the abdo abdome men. n. Blood Blood tests tests can can reve reveal al abno abnorm rmal al leve levels ls of bilirubin, cholesterol, serum proteins, urea, ammonia, and various enzymes. A specific diagnosis of a liver problem can be established by performing a needle biopsy. Bacterial abscess of the liver is relatively rare. It has been described since the time of Hippocrates (400 BC), with the first published review by Bright appearing in 1936. In 1938, Ochsner's classic review heralded surgical drainage as the definitive therapy; howe however ver,, despi despite te the the more more aggre aggressi ssive ve appr approa oach ch to treatm treatment ent,, the the mort mortali ality ty rate rate remained at 60-80%. The develop developmen mentt of new radiolo radiologic gic techniq techniques, ues, the improve improvemen mentt in microbi microbiolog ologic ic ident identifi ificat cation ion,, and and the advan advancem cemen entt of draina drainage ge techn techniqu iques, es, as well well as impro improved ved supportive care, have decreased mortality rates to 5-30%; yet, the prevalence of liver abscess has remained relatively unchanged. Untreated, this infection remains uniformly fatal.
Prior to the antibiotic era, liver abscess was most common in the fourth and fifth decades of life, primarily due to complications of appendicitis. With the development of better diagnostic techniques, early antibiotic administration, and the improved survival of the general general population, population, the demogra demographic phic has shifted shifted toward toward the sixth sixth and seventh seventh decades of life. Frequency curves display a small peak in the neonatal period followed by a gradual rise beginning at the sixth decade of life. Cases of liver abscesses in infants infants have been been associat associated ed with umbilica umbilicall vein vein catheter catheterizat ization ion and sepsis. sepsis. When When abscesses abscesses are seen in children and adolescents, underlying immune deficiency, severe malnutrition, or trauma frequently exists.
Goals and Objec bjectives of the study
1. To have have an in-depth in-depth understanding understanding of of the Hepatic Hepatic abscess abscess disease. 2. Give appropriate appropriate application application of physical physical assessment assessment to detect actual and potential health problems which are to be given priority 3. Promote health education education in relation relation to the health health condition condition of the patient. patient. 4. To determine determine the proper interventio intervention n regarding regarding the health health care management management on the presenting disease and its associated complication.
CLIENT’S PROFILE Name: Mr. A Address: Balingasag, Misamis Oriental Sex: Male Age: 29 years old Height: 5 feet and 5 inches / 168cm Weight: 149 pounds/ 68 kilograms Occupation: Farmer Civil Status: Married Nationality: Filipino Religion: Roman Catholic Date of Admission: January 10, 2010 Admitting Diagnosis: Hepatic Abscess Chief Complaint: Intermittent epigastric pain.
History of Present Illness: One week before admission, patient A noted onset of moderate grade fever associated with chills and epigastric pain. Patient a tolerated his condition and no consult done. Two days prior to admission, the patient would still have recurrence of fever episodes and increasing abdominal pain. Thus finally consulted at Balingasag Medical hospital and was admitted as a case of urinary tract infection. Eventually referred at Northern Mindanao Medical Center, hence admitted.
Personal, Environmental and Psychosocial History: Mr. A’s educational attainment was limited up to Grade 5 thus prompted him to work as a farmer in Balingasag, Misamis Oriental. He was married to Mrs. A in 2000. Mrs. A manages a small convenient store near their house. The couple have two daughters and all of them are still dependent on the family. During the assessment, Mr. P stated that he has been a tobacco user for eleven years and smokes half to 1 pack per day. He also added that he has been drinking alcoholic beverages mostly five bottles thrice a week. He takes coffee occasionally for at least one glass per day. He has no known allergies. He doesn’t exercise but plays basketball leisurely.
Physical Assessment: Initial Assessment: January 14, 2010 Final Assessment: January 16, 2010
General Survey Initial Assessment Mr. A was lying on his bed in a semi-
Final Assessment Mr. A was sitting at the right side of his
fowlers position; considerable in size;
bed; ambulatory; 46 kilograms. Wearing a
48 kilograms, 5 feet and 5 inches in
white t-shirt and generally appears clean;
height; and generally appears dusky;
fully
fully
conscious
surroundings;
and
hoarse
aware voice,
conscious
of surroundings;
and
still
aware
with
of
ongoing
with intravenous fluid of PNSS at 900 level
ongoing intravenous fluid of Plain
running at 30 drops per minute, patent
Normal Saline Solution (PNSS) at 600
and infusing well at the left metacarpal
milliliters level, running at 30 drops per vein. Mr. A was accompanied by his wife. minute, patent and infusing well at the left
metacarpal
vein.
Mr.
A
was
accompanied by his wife.
Fully
Central Nervous System Initial Assessment Final Assessment conscious and aware of Alert and oriented to time, place and
surroundings; communicates verbally person; with a GCS of 15; sensory and actively; with Glasgow Coma Scale
functions intact, no numbness, tingling or
(GCS) of 14 (spontaneous eye opening,
burning
sensation
4; oriented and converses clearly, 5;
functions
were
and
5);
balance and stance for more than 5
no
seconds when asked to stand.
localizes
sensory
painful
functions
numbness,
tingling
stimuli, intact, or
reported;
intact;
can
motor maintain
burning
sensation reported; motor functions were intact; Cardiovascular System Initial Assessment Final Assessment Mr. A showed cardiac rate of 67 beats Cardiac rate of 65 bpm, oxygen saturation per minute, oxygen saturation of 95%;
of 95%.Blood pressure of 120/80mmH,
blood pressure of 120/90 mmHg taken
with pulse pressure of 40. Capillary refill
on the right arm, with pulse pressure
of 2 seconds. Pinkish nail bed. Peripheral
of 30; jugular vein was not visible; on
pulses with regular rate and rhythm.
auscultation, no heart murmurs heard;
Jugular
no
precordial area.
evidence
of
bleeding;
with
a
vein
was
not
visible.
Flat
capillary refill of 3 seconds; pale nail beds, no clubbing noted; with regular rate and rhythm of peripheral pulses; Respiratory System Initial Assessment Head of the bed elevated to 35-45 degree
angle;
with
evidence
Final Assessment Breathing pattern with respiratory of 24
of cpm. Lung expansion symmetrical as well
difficulty of breathing; nasal flaring
as
noted. With a respiratory rate of 30
endotracheal and mechanical ventilator
cycles per minute;
no
tactile
fremitus.
Still
with
no
mechanical attached.
ventilator and endotracheal tube in place; symmetrical chest expansion; use
of
accessory
muscles
were
evident; no barrel chest noted. Spine was ventrically aligned; chest wall intact, no tenderness noted.
Upon
Gastrointestinal System Initial Assessment Final Assessment inspection, abdomen was Abdomen was uniform in color. Still no
uniform in color, rounded; no palpation
palpation and percussion allowed.
and percussion of abdomen as ordered by the physician. Urinary System Initial Assessment No urinary catheter noted urine output
Final Assessment No urinary catheter noted; Mr. A reported
was 100mL for the last two hours; no
that he had no difficulty in urinating; he
hematuria
added that he urinated thrice in the last
noted;
bladder
not
distended.
two hours and failed to measure it; bladder not distended.
Integumentary System Initial Assessment Uniform deep brown skin color except
Final Assessment No pressure sores, wounds, abrasions or
in areas exposed to the sun; no
other lesions noted; with good elasticity.
pressure sores, wounds, abrasions or other lesions noted; skin sprang back to previous state when pinched.
Musculoskeletal System Initial Assessment Final Assessment Equal size on both sides of the body; Full range of motion, equally strong in no
weakness
or
paralysis;
no
contracture in muscles and tendon;
muscle tone and strength. Spine is in midline.gait is coordinated.
tremors was not evident; muscles were firm at rest with equal strength on each body
side;
no
deformities;
no
tenderness noted; full range of motion; no joint pain or stiffness; was able to turn from side to side. Psychosocial System Initial Assessment Final Assessment Mr. A expressed that it was hard for Patient has understood the nature of his him to be hospitalized and experienced
illness but still eager to get well and to
difficulties
recover soon since he misses the quiet
due
to
his
disease.
However, he was hopeful that he can recover very soon as he modifies and strengthens his lifestyle by complying with his medical regimen. His support system was not adequate tho.
environment at home.
ANATOMY AND PHYSIOLOGY
LIVER
The Liver: Anatomy and Functions Anatomy of the liver: The liver is considered the largest organ in the body and is located in the upper righthand portion of the abdominal cavity, beneath the diaphragm, and on top of the stomach, right kidney, and intestines. Shaped like a cone, the liver is a dark reddishbrown organ that weighs about 3 pounds.
There are two distinct sources that supply blood to the liver, including the following: • •
oxygenated blood flows in from the hepatic artery nutrient-rich blood flows in from the hepatic portal vein
The liver holds about one pint (13 percent) of the body's blood supply at any given moment. The liver consists of two main lobes, both of which are made up of thousands of lobules. These lobules are connected to small ducts that connect with larger ducts to ultimately form the hepatic duct. The hepatic duct transports the bile produced by the liver cells to the gallbladder and duodenum (the first part of the small intestine). The liver has a multitude of important and complex functions. Some of these functions are to: •
•
•
•
Manufacture (synthesize) proteins, including albumin (to help maintain the volume of blood) and blood clotting factors Synthesize, store, and process (metabolize) fats, including fatty acids (used for energy) and cholesterol Metabolize and store carbohydrates, which are used as the source for the sugar (glucose) in blood that red blood cells and the brain use Form and secrete bile that contains bile acids to aid in the intestinal absorption (taking in) of fats and the fat-soluble vitamins A, D, E, and K.
•
•
Eliminate, by metabolizing and/or secreting, the potentially harmful biochemical products produced by the body, such as bilirubin from the breakdown of old red blood cells and ammonia from the breakdown of proteins Detoxify, by metabolizing and/or secreting, drugs, alcohol, and environmental toxins
The liver synthesizes and transports bile pigments and bile salts that are needed for fat digestion. Bile is a combination of water, bile acids, bile pigments, cholesterol, bilirubin, phospholipids, potassium, sodium, and chloride. Primary bile acids are produced from cholesterol. When bile acids are converted or "conjugated" in the liver, they become bile salts. Bilirubin is the main bile pigment that is formed from the breakdown of heme in red blood cells. The broken-down heme travels to the liver, where is it secreted into the bile by the liver. Bilirubin production and excretion follow a specific pathway. When the reticuloendothelial system breaks down old red blood cells, bilirubin is one of the waste products. This "free bilirubin" is a lipid soluble form that must be made water-soluble to be excreted. The conjugation process in the liver converts the bilirubin from a fat-soluble to a water-soluble form. The liver also plays a major role in excreting cholesterol, hormones, and drugs from the body. The liver plays an important role in metabolizing nutrients such as carbohydrates, proteins, and fats. The liver helps metabolize carbohydrates in three ways: •
•
•
Through the process of glycogenesis, glucose, fructose, and galactose are converted to glycogen and stored in the liver. Through the process of glycogenolysis, the liver breaks down stored glycogen to maintain blood glucose levels when there is a decrease in carbohydrate intake. Through the process of gluconeogenesis, the liver synthesizes glucose from proteins or fats to maintain blood glucose levels.
The liver synthesizes about 50 grams of protein each day, primarily in the form of albumin. Liver cells also chemically convert amino acids to produce ketoacids and ammonia, from which urea is formed and excreted in the urine. Digested fat is converted in the intestine to triglycerides, cholesterol, phospholipids, and lipoproteins. These substances are converted in the liver into glycerol and fatty acids, through a process known as ketogenesis. Prothrombin and fibrinogen, substances needed to help blood coagulate, are both produced by the liver. The liver also produces the anticoagulant heparin and releases vasopressor substances after hemorrhage. Liver cells protect the body from toxic injury by detoxifying potentially harmful substances. By making toxic substances more water soluble, they can be excreted from the body in the urine. The liver also has an important role in vitamin storage. High concentrations of riboflavin or Vitamin B1 are found in the liver. 95% of the body's vitamin A stores are concentrated in the liver. The liver also contains small amounts of Vitamin C, most of the body's Vitamin D stores, and Vitamins E and K.
Pathophysiology Predisposing Factor: Age: 29 y.o. Gender: Male Chronic alcohol drinker (for almost 11 years) Occupation: Farmer Poor hygiene
Precipitating Factor: Unsanitary food handing
Infection of liver
Activation of inflammatory response
Release of kinins, histamine, and other chemicals (chemical “alarms”)
Blood vessels dilate
Capillaries become “leaky”
Increased blood flow into the area
Neutrophils, monocytes and other WBCs enter the area
Decreased albumin
Decreased oncotic pressure, Increased hydrostatic pressure Redness •
Heat Fever
Fluids and proteins leave the blood vessel going to interstitial spaces of tissue
Increased metabolic rate of tissue cells
Edema
Paracetamol 500mg, PO
Pain
Swelling
Malaise Abdominal pain (RUQ)
Medical Management: metronidazole q8h, IVTT ciprofloxacin 500mg 1 tab, bid, PO
Failure of inflammatory mechanism
•
•
Tramadol 50 mg, q8h, IVTT
Severe infection
Hematology Report: (Jan. 10, 2010) WBC-20.9 x 10^3/uL •
Uncleared area of debris
Sac of pus (mixture of dead neutrophils, broken-down tissue cells, dead pathogens)
Decreased oncotic pressure, Increased hydrostatic pressure Redness •
Heat Fever
Fluids and proteins leave the blood vessel going to interstitial spaces of tissue
Increased metabolic rate of tissue cells
Edema
Paracetamol 500mg, PO
Pain
Swelling
Malaise Abdominal pain (RUQ)
Medical Management: metronidazole q8h, IVTT ciprofloxacin 500mg 1 tab, bid, PO
Failure of inflammatory mechanism
•
•
Tramadol 50 mg, q8h, IVTT
Severe infection
Hematology Report: (Jan. 10, 2010) WBC-20.9 x 10^3/uL •
Uncleared area of debris
Sac of pus (mixture of dead neutrophils, broken-down tissue cells, dead pathogens)
Pus are walled off the liver
HEPATIC ABSCESS Blockage of bile duct
Prevents bile from entering small intestine
Hepatomegaly
Bile accumulates and backs-up into the liver
Pressure on liver cells
Proteins enter bloodstream
Circulation of proteins
Enters kidney circulation
Bile salts and bile pigments enter bloodstream
Circulation of bile pigments
Jaundice
Icteric sclera
Uncleared area of debris
Sac of pus (mixture of dead neutrophils, broken-down tissue cells, dead pathogens)
Pus are walled off the liver
HEPATIC ABSCESS Blockage of bile duct
Prevents bile from entering small intestine
Hepatomegaly
Bile accumulates and backs-up into the liver
Pressure on liver cells
Proteins enter bloodstream
Bile salts and bile pigments enter bloodstream
Circulation of proteins
Circulation of bile pigments
Enters kidney circulation
Protein in urine (Proteinuria)
Jaundice
Icteric sclera
Lab Result: Protein (+2)
LABORATORY RESULTS
Proteins enter bloodstream
Bile salts and bile pigments enter bloodstream
Circulation of proteins
Circulation of bile pigments
Enters kidney circulation
Protein in urine (Proteinuria)
Jaundice
Icteric sclera
Lab Result: Protein (+2)
LABORATORY RESULTS Blood Chemistry Dr. Sarmiento
01-13-10
RESULTS
REFERENCE
Blood urea nitrogen
= 15.22
(4.6 – 23.4) mgs. %
Creatinine
= 0.73
(0.6 – 1.2) mgs. %
Potassium
= 3.27
(3.5 – 5.3)mmol/L
Sodium
= 134.2
(135 – 148)mmol/L
INTERPRETATI ON Normal Normal Low potassium resulting to have muscle weakness, muscle aches, and muscle cramps. Hyponatremia, result to experience nausea, vomiting, headache and malaise.
LABORATORY RESULTS Blood Chemistry Dr. Sarmiento
01-13-10
RESULTS
REFERENCE
Blood urea nitrogen
= 15.22
(4.6 – 23.4) mgs. %
Creatinine
= 0.73
(0.6 – 1.2) mgs. %
Potassium
= 3.27
(3.5 – 5.3)mmol/L
Sodium
= 134.2
(135 – 148)mmol/L
INTERPRETATI ON Normal Normal Low potassium resulting to have muscle weakness, muscle aches, and muscle cramps. Hyponatremia, result to experience nausea, vomiting, headache and malaise.
ULTRASOUND REPORT January 13, 2010 Tentative Diagnosis: FINDINGS: The left lobe is enlarged. A complex hypoechoic mass measuring 9.6 cm x 8.8 cm x 7.3 cm seen in its medial aspect. The right hepatic lobe is uremarkable. Gallbladder is normal in size. Its wall is not thickened. No intraluminal mass or lithiasis seen. Pancreas is unremarkable. DIAGNOSIS: 1.) COMPLEX, HYPOECHOIC MASS, MEDIAL ASPECT OF THE LEFT HEPATIC LOBE, POSSIBLY AN ABCESS 2.) NON – REMARKABLR ULTRASOUND FINDINGS IN THE GALLBLADDER AND PANCREAS
INTERPRETATION:
Hypoechoic on ultrasound means dark, in liver at times there is inhomogenous fat deposition which appear which appears bright and areas of sparing appear dark or hypoechoic and can times mimic mass on ultasound
URINALYSIS REPORT January 14, 2010 INTERPRETATION PHYSICAL PROPERTIES:
Color
yellow
Clarity
Hazy
pH
7.5
Specific gravity
1.015
Excess sweating, also a sign that patient is not been drinking enough liquids Detected albumin, globulins, and Bence-Jones protein at low concentrations Alkaline, a risk for infection Normal, within the range from 1.003 – 1.030
CHEMICAL PROPERTIES:
proteins
trace
Glucose
negative
Normal Normal
SEDIMENT/MICROSCOPIC EXAMINATION
Epithelial cells
Moderate
Puss cells (WBC)
2-3
Red blood cells
4-6
Bacteria
Few
Normal Kidney or bladder injury or UTI UTI
URINALYSIS REPORT January 10, 2010 INTERPRETATION PHYSICAL PROPERTIES:
Color
Dark yellow
Clarity
Cloudy
pH
5.0
Specific gravity
1.030
Liver problems or jaundice Excessive cellular material or protein in the urine Acidic, normal normal
CHEMICAL PROPERTIES:
proteins
+2
Glucose
negative
May have kidney damage, an infection, alteration of liver function Normal
SEDIMENT/MICROSCOPIC EXAMINATION
Puss cells (WBC)
4-6
Red blood cells
2-3
Coarsely granular
0-2
Mucus threads
few
Pyuria, infection in either the upper or lowe urinary tract Kidney or bladder injury or UTI high salt concentration Mucus threads are usually present in small numbers. Increased numbers are indicative of chronic inflammation of the urethra and bladder.
FECALYSIS
January 10, 2010 INTERPRETATION PHYSICAL CHARACTERISTIC yellow
Color and character consistency
watery
PARASITIC ORGANISM Negative for any amoeba and other intestinal parasitic ova
Normal Diarrhea Normal
HEMATOLOGY REPORT January 13, 2010 TEST WHITE BLOOD CELS RED BLOOD CELLS HEMOGLOBIN
RESULT 14.1
UNIT 10^3/uL
REFERENCE 5.0 – 10.
INTERPRETAION
3.68
10^6/uL
4.2 – 5.4
Anemic
11.0
g/dL
12.0 – 10.0
HEMATOCRIT
32.8
%
37.0 – 47.0
MCV
89.1
fL
82.0 – 98.0
MCH
29.9
Pg
27.0 – 31.0
MCHC
33.5
g/dL
31.5 – 35.0
RDW-CV
15.8
%
12.0 – 17.0
PDW
10.0
fl
9.0 – 16.0
MPV
8.6
fL
8.0 – 12.0
Normal signal conditions such as anemia, bone marrow problems, dehydration Normal Normal Normal Normal Normal Normal
DIFFERENTIAL COUNT Lymphocyte (%)
18.2
%
17.4 – 48.2
Neutrophil (%)
66.0
%
43.4 – 76.2
Monocyte (%)
15.8
%
4.5 – 10.5
Eusinophils (%)
0.0
%
1.0 – 3.0
Basophils (%)
0.0
%
0.0 – 2.0
%
1.0 – 2.0
10^3/uL
150 - 400
Bands/scabs (%) PLATELET
REMARKS
264
Infection
Normal Normal Infection infection or an inflammatory process in the body Normal --Normal
TEST WHITE BLOOD CELS RED BLOOD CELLS HEMOGLOBIN
RESULT 20.9
UNIT 10^3/uL
REFERENCE 5.0 – 10.
INTERPRETATION
4.50
10^6/uL
4.2 – 5.4
Normal
13.0
g/dL
14.0 – 16.0
HEMATOCRIT
40.4
%
37.0 – 47.0
MCV
89.8
fL
82.0 – 98.0
MCH
30.0
Pg
27.0 – 31.0
MCHC
33.4
g/dL
31.5 – 35.0
RDW-CV
%
12.0 – 17.0
PDW
fl
9.0 – 16.0
MPV
fL
8.0 – 12.0
poor diet/nutrition or malabsorption Normal Normal Normal Normal -------
DIFFERENTIAL COUNT Lymphocyte (%)
7.3
%
17.4 – 48.2
Neutrophil (%)
82.0
%
43.4 – 76.2
Monocyte (%)
10.7
%
4.5 – 10.5
Eusinophils (%)
%
1.0 – 3.0
Basophils (%)
%
0.0 – 2.0
Bands/scabs (%)
%
1.0 – 2.0
10^3/uL
150 - 400
PLATELET
221
Infection
Risk for infrction Elevated levels of neutrophils may occur when the body is fighting a flu or other infection infection ------Normal
HEMATOLOGY REPORT January 10, 2010
NURSING CARE PLAN Nursing Diagnosis Ineffective Tissue Perfusion related to interruption of venous flow Assessment Data Subjective: “Maglisod ko ug ginhawa bisan maghigda.” as verbalized by the patient Objective: Capillary refill of about 3 seconds assessed Pallor Muscle wasting • • •
Goals and Objectives: Long term goal: After 2 days of nursing care, the patient will be able to demonstrate lifestyle changes to improve circulation. Short term goal: After 4 hours of nursing care, the patient will be able to demonstrate increased perfusion as appropriate, as evidenced by: a. Respiration within normal range b. Balanced intake and output Nursing Interventions: Independent: •
•
•
Assist patient in ROM exercises (exercises prevent venous stasis) Proper positioning of patient, change every 2 hrs. (This promotes optimal ventilation and perfusion) Teach patient breathing relaxation technique (to improve oxygen demand of patient)
Elevate head of bed. Rationale: To increase gravitational blood flow •
Encourage use of relaxation techniques Rationale: To decrease tension level •
Dependent: Emphasize importance of avoiding use of aspirin, some OTC drugs, vitamins containing potassium, mineral oil or alcohol when taking anticoagulants. Rationale: •
Evaluation: Goals partially met, as evidenced by: 24 cpm Capillary refill 2 sec Demonstrate proper breathing relaxation technique • • •
NURSING DIAGNOSIS -
Ineffective breathing pattern related to pain
ASSESSMENT DATA (SUBJECTIVE AND OBJECTIVE CUES Subjective: “Usahay galisod ko og ginhawa maam” as verbalized Objective: - Tachypnea RR = 30 - Nasal Flaring - Use of accessory muscle - Pallor - pain scale 10/10 GOALS AND OBJECTIVE Short term Goal: At the end of 30 minutes of nursing intervention the patient will: - Have adequate ventilation as evidenced by: a.respiration within normal range from 30 cpm to 20 cpm b.absence of nasal flaring c.do not use of accessory muscle Long term goal: At the end of 1 day of nursing intervention the patient will: - demonstrate appropriate coping behavior NURSING INTERVENTION Independent Elevate head of bed or position patient in a semi fowler’s position (to promote physiological/psychological ease of maximal inspiration) •
•
•
Encourage deep breathing exercise by using purse-lip technique (to take control of the situation) Assist client in the use of relaxation technique like breathing exercise (to promote rest) •
•
•
Provide comfort position to patient (to prevent uneasiness ) Ambulate patient and assist in exercise as tolerated (maximize patient’s level of functioning)
Encourage adequate rest period between exercise (to prevent fatigue) Dependent Administer analgesic, if recommended by the physician (promotes respiration) •
•
EVALUATION Goals partially met - The patient’s respiration is 24 cpm - absence of nasal flaring and use muscle accessory
NURSING CARE PLAN NURSING DIAGNOSIS: Acute Pain related to presence of pus in the liver. ASSESSMENT DATA: SUBJECTIVE CUE: “ Sakit akoang tiyan sa tuo dapit,”as verbalized. OBJECTIVE CUES:
-
Observed evidence of pain
-
Muscle guarding noted with pain scale of 10/10.
-
Facial Grimace noted.
-
Expressive behavior observed ( sighing )
-
Doctor ordered not to palpate patient abdomen
GOALS AND OBJECTIVE: Short term goal: After 30 minutes of nursing interventions, the patient pain will decreased from • 10/10 to 5/10. Long term goal: After 8 hours of nursing intervention, the patient’s pain will be relieved from 5/10 • to 0. NURSING INTERVENTIONS: •
•
•
•
•
Accept client’s description of pain. Acknowledge the pain experience and convey acceptance of client’s response to pain. R: pain is subjective experience and cannot be felt by others. Observe nonverbal cues/pain behaviors (e.g., how the patient walks, holds body, sits; facial expression; cool fingertips/toes, which can mean constricted blood vessels) and other objective cues, as noted. R: observations may/may not be congruent with verbal reports or may be only indicator present when client is unable to verbalize. Determine patient’s acceptable level of pain/pain control goals. R: it may vary to individuals coping capabilities. Provide comfort measures (e.g., touch, repositioning, use of heat/cold packs, nurse’s presence) quiet environment, and calm activities. R: to promote nonpharmacological pain management. Instruct patient to encourage use of relaxation techniques such as focused breathing, imaging and listening to calming music. Encourage also diversional activities. R: to distract attention and reduce tension.
•
Administer analgesics, as indicated, to maximum dosage, as needed. R: to maintain acceptable level of pain. Notify the physician if regimen is in adequate to meet pain control goal.
EVALUATION: GOALS PARTIALLY MET ,as evidenced by: Pain scale of 5/10.
NURSING CARE PLAN Nursing Diagnosis - Hyperthermia related to increased metabolic rate Assessment Data Subjective: “Sugod pa ko gihilantan atong pag-admit nako”, as verbalized by the patient. Objective: • • • •
Increased body temperature (T= 37.8°C) assessed Skin is warm and dry to touch noted Increased respiratory rate (RR= 30 cpm) assessed Firm skin turgor noted
Goals and Objectives: Long term goal: At the end of 30 minutes, the patient will be able to display signs of wellness, as evidenced by reduced body temperature from 37.8°C to 37.5C. Short term goal: After 1 hour of nursing care, the patient will be able to identify contributing factors and importance of treatment. Nursing Interventions: Independent: Monitor vital signs. Rationale: To provide a baseline data •
Promote surface cooling by means of tepid sponge bath Rationale: To promote heat loss by means of evaporation •
Discuss importance of adequate fluid intake. Rationale: To prevent dehydration •
Maintain bedrest. Rationale: To reduce metabolic demands and oxygen consumption •
Dependent: Administer antipyretics, as ordered. paracetamol 500mg 1 tab, q4hrs for T≥38.0 •
•
Administer medications as indicated to treat underlying cause. Ciprofloxacin 500mg 1tab, twice a day Indication: For treatment of infections caused by susceptible gramnegative bacteria, including Escherichia coli •
Evaluation: GOALS MET. The patient’s temp. is 37.5.
NURSING CARE PLAN Nursing Diagnosis - Imbalanced Nutrition: Less than body requirements related to increased metabolic demands. Assessment Data Subjective: " magsakit akong tiyan kung magkaon" as verbalized by the patient. Objective: Body mass index: 17.5 pale conjunctiva Abnormal laboratory findings a. RBC 3.68 • • •
Goals and Objectives: Long term goal: At the end of 8 hours, patient will be able to demonstrate behaviors, lifestyle changes to regain and maintain appropriate weight. Short term goal:
At the end of 1 hours patient will be able to verbalized understanding of causative factors when known and necessary interventions.
Nursing Interventions: Independent: Provide small frequent meals. Rationale: To prevent nausea and vomiting. Served high fiber diet. Rationale: To prevent constipation. Increase fluid intake to 2-3 liters/ day. Rationale: To manage fluid imbalanced. Encouraged exercise as tolerated like passive ROM. R: To improve metabolism. Dependent: Use flavoring agents. Rationale: To enhance food satisfaction and stimulate appetite. Collaborative: Consult a dietitian/ nutritional team as indicated. Rationale: To implement interdisciplinary team management. •
•
•
•
•
•
Evaluation: Goals not met. Weight of patient below normal range of body mass index 17.5.
Drug Study
DRUG ORDER
Generic name: Tramadol hydrochloride
Brand name: Ultram
Classification: Analgesic
MECHANISM OF ACTION An analgesic that binds to mu-opioid receptors and inhibits reuptake of norepinephrine and serotonin reduces the intensity of pain stimuli reaching sensory nerve endings.
INDICATIONS
CONTRAINDICATIONS
Management of moderate to moderately severe pain.
Acute alcohol intoxication, concurrent use of centrally acting analgesics, hypnotics, opioids, or psychotropic drugs, hypersensitivity to opioids.
Therapeutic Effect: Alters the perception of and emotional response to pain.
Seizures have been reported in patients receiving tramadol within the recommended dosage range. Overdose results in respiratory depression and seizures. Tramadol may not have prolonged duration of action and cumulative effect in patients with hepatic or renal impairment.
Dosage: 50mg
Frequency: q8h
Generic name: Metronidazole Brand name: Metronidazole Benzoate Classification: Antibacterial, antiprotozoal
Dosage: 750mg
Check the prescribed medication for 3 time on the first encounter, before and after withdrawing the med R> so that the medicine is properly checked according to the doctor’s prescription. Give first health teaching before giving the patient. R> to make the patient prepare and know what to expect The med should be given in IVTT route according to the doctor R> Follow the doctor’s order as prescribed to the patient.
Route: IVTT
DRUG ORDER
NURSING RESPONSIBILITIES/ PRECAUTIONS
ADVERSE EFFECTS OF THE DRUG
MECHANISM OF ACTION
INDICATIONS
A nitroimidazole derivative that disrupts bacterial and protozoal DNA, inhibiting nucleic acid synthesis.
For treatment of anaerobic infection (skin and skin structures, CNS, lower respiratory tract, bone and joints).
Therapeutic Effect: Produces bactericidal, antiprotozoal, amebicidal, and trichomonacidal effects. Produces antiinflammatory and immunosuppressive effects when applied topically.
Treatment of trichomoniasis, amebiasis, antibioticassociated pseudomembranous colitis (AAPC).
CONTRAINDICATIONS
ADVERSE EFFECTS OF THE DRUG
Hypersensitivity to other Peripheral neuropathy, nitroimidazole manifested as derivatives. numbness and tingling in hands or feet, is Cautions: blood usually reversible if dyscrasias, severe treatment is stopped hepatic dysfunction, immediately after CNS disease, neurologic symptoms predisposition to edema. appear. Seizures occur ocassionally.
NURSING RESPONSIBILITIES/ PRECAUTIONS Check the prescribed medication for 3 time on the first encounter, before and after withdrawing the med R> so that the medicine is properly checked according to the doctor’s prescription. Give first health teaching before giving the patient. R> to make the patient prepare and know what to expect
Route: IVTT
The med should be given in IVTT route according to the doctor R> Follow the doctor’s order as prescribed to the patient.
Frequency: q8h
Question for hypersensitivity on metronidazole R> to determine if the med is applicable to patient.
DRUG ORDER
Generic name: Ciprofloxacin hydrochloride
MECHANISM OF ACTION A fluoroquinolone that inhibits the enzyme DNA gyrase in susceptible bacteria,
INDICATIONS
For treatment of infections due to E. coli, K. pneumoniae, E. cloacae, P. mirabilis, P.
CONTRAINDICATIONS
Hypersensitivity to ciprofloxacin or other quinolones; for ophthalmic
ADVERSE EFFECTS OF THE DRUG
NURSING RESPONSIBILITIES/ PRECAUTIONS
Superinfection, pephropathy, cardiopulmonary arrest, chest pain, and cerebral
Question for hypersensitivity for the medicine R> since it will harm the
DRUG ORDER
Generic name: Metronidazole Brand name: Metronidazole Benzoate Classification: Antibacterial, antiprotozoal
Dosage: 750mg
MECHANISM OF ACTION
INDICATIONS
A nitroimidazole derivative that disrupts bacterial and protozoal DNA, inhibiting nucleic acid synthesis.
For treatment of anaerobic infection (skin and skin structures, CNS, lower respiratory tract, bone and joints).
Therapeutic Effect: Produces bactericidal, antiprotozoal, amebicidal, and trichomonacidal effects. Produces antiinflammatory and immunosuppressive effects when applied topically.
Treatment of trichomoniasis, amebiasis, antibioticassociated pseudomembranous colitis (AAPC).
CONTRAINDICATIONS
ADVERSE EFFECTS OF THE DRUG
Hypersensitivity to other Peripheral neuropathy, nitroimidazole manifested as derivatives. numbness and tingling in hands or feet, is Cautions: blood usually reversible if dyscrasias, severe treatment is stopped hepatic dysfunction, immediately after CNS disease, neurologic symptoms predisposition to edema. appear. Seizures occur ocassionally.
NURSING RESPONSIBILITIES/ PRECAUTIONS Check the prescribed medication for 3 time on the first encounter, before and after withdrawing the med R> so that the medicine is properly checked according to the doctor’s prescription. Give first health teaching before giving the patient. R> to make the patient prepare and know what to expect
Route: IVTT
The med should be given in IVTT route according to the doctor R> Follow the doctor’s order as prescribed to the patient.
Frequency: q8h
Question for hypersensitivity on metronidazole R> to determine if the med is applicable to patient.
DRUG ORDER
Generic name: Ciprofloxacin hydrochloride Brand name: Ciloxan
Classification: Anti-infective
MECHANISM OF ACTION A fluoroquinolone that inhibits the enzyme DNA gyrase in susceptible bacteria, interfering with bacterial cell replication. Therapeutic Effect: Bactericidal
Dosage: 500mg 1 tab
INDICATIONS
For treatment of infections due to E. coli, K. pneumoniae, E. cloacae, P. mirabilis, P. vulgaris, H. influenzae, Shigella species, S. typhi including intraabdominal, bone and joint, lower respiratory tract, skin and skinstructure, and urinary tract infections, infectious diarrhea, protastitis, sinusitis, typhoid fever febrile neutropenia.
CONTRAINDICATIONS
Hypersensitivity to ciprofloxacin or other quinolones; for ophthalmic administration: vaccinia, varicella. Cautions: renal impairment, CNS disorders, seizures, those taking caffiene.
ADVERSE EFFECTS OF THE DRUG Superinfection, pephropathy, cardiopulmonary arrest, chest pain, and cerebral thrombosis may occur. Hypersensitivity reaction, including photosensitivity (as evidenced by rash, pruritus, blisters, edema and burning skin) have occurred in patients receiving fluoronolones.
NURSING RESPONSIBILITIES/ PRECAUTIONS Question for hypersensitivity for the medicine R> since it will harm the patient Monitor for any dizziness, headache, visual changes, tremors. R> to determine client’s response to the med. Do not take with antacids R> since it could reduce or destroy the drug’s effectiveness.
Route: Oral Frequency: BID
DRUG ORDER
Generic name: Ranitidine hydrochloride
MECHANISM OF ACTION
INDICATIONS
An antiulcer agent that inhibits histamine action 2 receptors of gastric parietal cells.
For short term treatment of duodenal ulcer. Prevention of duodenal ulcer recurrence.
CONTRAINDICATIONS
History of acute porphyria. Cautions: renal or
ADVERSE EFFECTS OF THE DRUG Reversible hepatitis and blood dyscrasias occur rarely.
NURSING RESPONSIBILITIES/ PRECAUTIONS Obtain baseline liver/renal function tests. R> to determine if the patient’s organ could
DRUG ORDER
Generic name: Ciprofloxacin hydrochloride Brand name: Ciloxan
Classification: Anti-infective
MECHANISM OF ACTION A fluoroquinolone that inhibits the enzyme DNA gyrase in susceptible bacteria, interfering with bacterial cell replication. Therapeutic Effect: Bactericidal
Dosage: 500mg 1 tab
INDICATIONS
For treatment of infections due to E. coli, K. pneumoniae, E. cloacae, P. mirabilis, P. vulgaris, H. influenzae, Shigella species, S. typhi including intraabdominal, bone and joint, lower respiratory tract, skin and skinstructure, and urinary tract infections, infectious diarrhea, protastitis, sinusitis, typhoid fever febrile neutropenia.
CONTRAINDICATIONS
Hypersensitivity to ciprofloxacin or other quinolones; for ophthalmic administration: vaccinia, varicella. Cautions: renal impairment, CNS disorders, seizures, those taking caffiene.
ADVERSE EFFECTS OF THE DRUG Superinfection, pephropathy, cardiopulmonary arrest, chest pain, and cerebral thrombosis may occur. Hypersensitivity reaction, including photosensitivity (as evidenced by rash, pruritus, blisters, edema and burning skin) have occurred in patients receiving fluoronolones.
NURSING RESPONSIBILITIES/ PRECAUTIONS Question for hypersensitivity for the medicine R> since it will harm the patient Monitor for any dizziness, headache, visual changes, tremors. R> to determine client’s response to the med. Do not take with antacids R> since it could reduce or destroy the drug’s effectiveness.
Route: Oral Frequency: BID
DRUG ORDER
Generic name: Ranitidine hydrochloride
Brand name: Zantac
Classification: Antiulcer
Dosage: 150mg 1 tab
MECHANISM OF ACTION
INDICATIONS
An antiulcer agent that inhibits histamine action 2 receptors of gastric parietal cells.
For short term treatment of duodenal ulcer. Prevention of duodenal ulcer recurrence.
Therapeutic Effect: Inhibits gastric acid secretion when fasting, at night, or when stimulated by food, caffeine, or insulin. Reduces volume and hydrogen ion concentration of gastric juice.
CONTRAINDICATIONS
History of acute porphyria.
ADVERSE EFFECTS OF THE DRUG Reversible hepatitis and blood dyscrasias occur rarely.
Cautions: renal or hepatic impairment, elderly.
NURSING RESPONSIBILITIES/ PRECAUTIONS Obtain baseline liver/renal function tests. R> to determine if the patient’s organ could metabolize the drug Assess mental status of the elderly R> to determine if the drug affects the mental state of the patient Inform or give health teachings to patient on what to expect after drug administration like headache R> so that the patient would be aware about the side effects that he would experience
Route: Oral
Frequency: BID
DRUG ORDER
Generic name: Vitamin K Brand name:
MECHANISM OF ACTION
INDICATIONS
A fat-soluble vitamin that promotes hepatic formation of coagulation factors I, II, VII, IX, and
Antidote for hemorrhage induced by oral coagulants, hypoprothrombinemic
CONTRAINDICATIONS
Hypersensitivity.
ADVERSE EFFECTS OF THE DRUG A severe reaction (cramplike pain, chest pain, dyspnea, facial flushing, dizziness, rapid
NURSING RESPONSIBILITIES/ PRECAUTIONS Inform patient and SO that discomfort may occur with parenteral administration.
DRUG ORDER
Generic name: Ranitidine hydrochloride
Brand name: Zantac
Classification: Antiulcer
Dosage: 150mg 1 tab
MECHANISM OF ACTION
INDICATIONS
An antiulcer agent that inhibits histamine action 2 receptors of gastric parietal cells.
For short term treatment of duodenal ulcer. Prevention of duodenal ulcer recurrence.
Therapeutic Effect: Inhibits gastric acid secretion when fasting, at night, or when stimulated by food, caffeine, or insulin. Reduces volume and hydrogen ion concentration of gastric juice.
CONTRAINDICATIONS
History of acute porphyria.
ADVERSE EFFECTS OF THE DRUG Reversible hepatitis and blood dyscrasias occur rarely.
Cautions: renal or hepatic impairment, elderly.
NURSING RESPONSIBILITIES/ PRECAUTIONS Obtain baseline liver/renal function tests. R> to determine if the patient’s organ could metabolize the drug Assess mental status of the elderly R> to determine if the drug affects the mental state of the patient Inform or give health teachings to patient on what to expect after drug administration like headache R> so that the patient would be aware about the side effects that he would experience
Route: Oral
Frequency: BID
DRUG ORDER
Generic name: Vitamin K Brand name: AquaMEPHYTON Classification: Nutritional supplement, antidote, antihemorrhagic
MECHANISM OF ACTION A fat-soluble vitamin that promotes hepatic formation of coagulation factors I, II, VII, IX, and X.
INDICATIONS
Antidote for hemorrhage induced by oral coagulants, hypoprothrombinemic states due to vitamin K deficiency.
CONTRAINDICATIONS
Hypersensitivity.
Therapeutic Effect: Essential for normal clotting of blood.
ADVERSE EFFECTS OF THE DRUG A severe reaction (cramplike pain, chest pain, dyspnea, facial flushing, dizziness, rapid or weak pulse, rash diaphoresis, hypotension progressing to shock, cardiac arrest) occurs rarely just after IV administration.
Dosage: 1 ampule
Frequency: q24h
Generic name: Paracetamol Brand name:
Inform patient and SO that discomfort may occur with parenteral administration. R> to be aware what will be the expexted affect after administration of med Do not use OTC medication without physician’s approval R> this may interfer with platelet aggregation Assess for decrease in BP, increase in PR, complaint of abdominal or back pain, severe headache R> this may be evidence of hemorrhage
Route: IVTT
DRUG ORDER
NURSING RESPONSIBILITIES/ PRECAUTIONS
MECHANISM OF ACTION Paracetamol exhibits analgesic action by peripheral blockage of pain impulse generation.
INDICATIONS
For treatment of mild to moderate pain and fever.
CONTRAINDICATIONS
Hypersensitivity.
ADVERSE EFFECTS OF THE DRUG Nausea, allergic reaction, skin rashes, acute renal tubular necrosis.
NURSING RESPONSIBILITIES/ PRECAUTIONS The medication should be given in orally R> this is according to the doctor’s order.
DRUG ORDER
Generic name: Vitamin K Brand name: AquaMEPHYTON Classification: Nutritional supplement, antidote, antihemorrhagic
MECHANISM OF ACTION A fat-soluble vitamin that promotes hepatic formation of coagulation factors I, II, VII, IX, and X.
INDICATIONS
Antidote for hemorrhage induced by oral coagulants, hypoprothrombinemic states due to vitamin K deficiency.
CONTRAINDICATIONS
Hypersensitivity.
Therapeutic Effect: Essential for normal clotting of blood.
ADVERSE EFFECTS OF THE DRUG A severe reaction (cramplike pain, chest pain, dyspnea, facial flushing, dizziness, rapid or weak pulse, rash diaphoresis, hypotension progressing to shock, cardiac arrest) occurs rarely just after IV administration.
Dosage: 1 ampule
NURSING RESPONSIBILITIES/ PRECAUTIONS Inform patient and SO that discomfort may occur with parenteral administration. R> to be aware what will be the expexted affect after administration of med Do not use OTC medication without physician’s approval R> this may interfer with platelet aggregation Assess for decrease in BP, increase in PR, complaint of abdominal or back pain, severe headache R> this may be evidence of hemorrhage
Route: IVTT Frequency: q24h
DRUG ORDER
Generic name: Paracetamol Brand name: Boigesic
Classification: Analgesics and Antipyretics
Dosage: 500mg
MECHANISM OF ACTION Paracetamol exhibits analgesic action by peripheral blockage of pain impulse generation. It produces antipyresis by inhibiting the hypothalamic heat – regulating center. Its weak anti-inflammatory activity is related to inhibition of prostaglandin synthesis in the CNS.
INDICATIONS
For treatment of mild to moderate pain and fever.
CONTRAINDICATIONS
Hypersensitivity.
ADVERSE EFFECTS OF THE DRUG
NURSING RESPONSIBILITIES/ PRECAUTIONS
Nausea, allergic reaction, skin rashes, acute renal tubular necrosis.
The medication should be given in orally R> this is according to the doctor’s order.
Potentially Fatal: Very rare, blood dyscrasias (e.g., thrombocytopenia, leukopenia, neutropenia, agranulocytosis); liver damage.
Assess patient for any drug allergy to the medicine. R> to determine if the patient is allergic to drug
Route: Oral
Intruct the patient/ give first health teaching before giving the patient. R> to make the patient prepare and know what to expect Give only the med for presence of fever or pain R> overdose could lead to drug-resistance
Frequency: PRN or q4h for temp.380C
HEALTH TEACHINGS Treatment of hepatic abs
nditio
be life-threatenin
in 10-30% of
DRUG ORDER
Generic name: Paracetamol Brand name: Boigesic
Classification: Analgesics and Antipyretics
Dosage: 500mg
MECHANISM OF ACTION Paracetamol exhibits analgesic action by peripheral blockage of pain impulse generation. It produces antipyresis by inhibiting the hypothalamic heat – regulating center. Its weak anti-inflammatory activity is related to inhibition of prostaglandin synthesis in the CNS.
INDICATIONS
For treatment of mild to moderate pain and fever.
CONTRAINDICATIONS
Hypersensitivity.
NURSING RESPONSIBILITIES/ PRECAUTIONS
ADVERSE EFFECTS OF THE DRUG Nausea, allergic reaction, skin rashes, acute renal tubular necrosis.
The medication should be given in orally R> this is according to the doctor’s order.
Potentially Fatal: Very rare, blood dyscrasias (e.g., thrombocytopenia, leukopenia, neutropenia, agranulocytosis); liver damage.
Assess patient for any drug allergy to the medicine. R> to determine if the patient is allergic to drug
Route: Oral
Intruct the patient/ give first health teaching before giving the patient. R> to make the patient prepare and know what to expect Give only the med for presence of fever or pain R> overdose could lead to drug-resistance
Frequency: PRN or q4h for temp.380C
HEALTH TEACHINGS Treatment of hepatic abscess condition can be life-threatening in 10-30% of patients. The risk is higher in people who have many abscesses. That’s why treatment usually consists of surgery or going through the skin with a needle or tube (percutaneous) to drain the abscess. Along with the procedures, the patient will also receive long-term antibiotic therapy (usually 4 - 6 weeks), because sometimes antibiotics alone can cure the infection. If not, life-threatening sepsis can develop. That’s why we stress the importance of the following:
•
Explain the disease process, causes, contributing factors, care and treatment. In order for the patient to understand his condition and for him to be able to participate in improving it.
•
Discuss the proper use medication. Explain the purpose, dosage, schedule, and route of administration of any prescribed drugs, as well as side effects to report to the physician or nurse.
•
Teach signs and symptoms that require immediate medical attention. Such as chalk-colored stool, dark urine, fever, chills, loss of appetite, nausea, vomiting, and pain in right abdomen (more common) or through out the abdomen, & unintentional weight loss.
HEALTH TEACHINGS Treatment of hepatic abscess condition can be life-threatening in 10-30% of patients. The risk is higher in people who have many abscesses. That’s why treatment usually consists of surgery or going through the skin with a needle or tube (percutaneous) to drain the abscess. Along with the procedures, the patient will also receive long-term antibiotic therapy (usually 4 - 6 weeks), because sometimes antibiotics alone can cure the infection. If not, life-threatening sepsis can develop. That’s why we stress the importance of the following:
•
Explain the disease process, causes, contributing factors, care and treatment. In order for the patient to understand his condition and for him to be able to participate in improving it.
•
Discuss the proper use medication. Explain the purpose, dosage, schedule, and route of administration of any prescribed drugs, as well as side effects to report to the physician or nurse.
•
Teach signs and symptoms that require immediate medical attention. Such as chalk-colored stool, dark urine, fever, chills, loss of appetite, nausea, vomiting, and pain in right abdomen (more common) or through out the abdomen, & unintentional weight loss.
•
Explain the importance of maintaining fluid and electrolytes balance.
Monitoring for fluid and electrolytes balance
Assess intake and output.
Weigh
patient daily. Tell the client and family members to maintain the ideal body weight of the patient, by weighting the client daily and record the result if necessary.
•
Assess presence and extent of edema.
Encouraging patient to increase fluid intake.
Discuss and encourage proper techniques in preventing further infection and injury.
Promoting proper skin and wound care.
Maintaining good personal hygiene.
Avoiding stress which can aggravate symptoms.
Encouraging activity within prescribed limits but avoid fatigue.
Protecting from injury when carrying out activities.
Protecting patient from exposure to infectious agents.
Maintaining good asepsis during treatments and procedures.
Encouraging proper diet.
•
Teach the family of how to promote comfort.
Medicating patient as needed for pain.
Providing comfort measures and relaxation techniques.
Encouraging good oral hygiene.
Encouraging rest for fatigue.
Providing calm, supportive environment
•
Tell the family to assist with coping in life-style and self-concept.
Promoting hope
Providing opportunity for patient to express feelings about self.
Therapeutic passes - Passes help the patient adjust to the home
environment and to practiced self care activities at home and help the family adjust to living with patient and to any alterations in physical, cognitive, and emotional functioning (after discharge). Remind also the family members to support the patient in his activity of daily living, and let them explain to the patient how it benefits for him to be as independent as possible. Tell also the family members to encourage the patient, within his condition’s capacity, to perform many self-care activities as possible.
DISCHARGE PLAN Medications:
Exercises
Patient is advised to take all the medications prescribed by the physicians as to the prescribed dosage, prescribed route, prescribed time and as on how many days will it be consumed. This will help the patient for fast recovery and prevention to further complication. >regular exercises like walking, stretching and other form of activities that would help maintain joint mobility & enhance circulation >Avoiding strenuous activities.
Treatment:
Very important treatment includes strict compliance to the prescribed medication most especially significance
antibiotic of
therapy
nutritional
and
the
supplements
promoting healing of the damage liver cells and improves general nutritional status.
Health teaching:
With emphasis on: >compliance to medication regimen > importance of proper diet. >avoidance of alcoholic beverages > importance of immediate consultation whenever symptoms of complications or progression of disease occurs like, vomiting and seizures, painful abdomen, trouble breathing all of the sudden, or any. >importance of good hygiene >significance of adequate rest
Out-Patient:
Patient should return to the institution one or two-weeks after discharge for follow-up check-up on his physician for health assessment, and faster recovery
Diet:
>Patient encouraged having adequate nutritional supplements. >Encouraged to eat variety of healthy foods such as fruits, vegetables, whole-grain breads, low-fat dairy products, beans, lean meat and fish. Eating healthy foods may help him have more energy and heal faster.
Spiritual:
Significant others were reminded to continue offer emotional support to patient and help to strengthen his spiritual faith so that patient will both have spiritual and emotional outlet to avoid depression.
LEARNING EXPERIENCE As new day arises, new trials are challenging us, testing every learning and knowledge we obtain in the previous days. There are many choices that surround us but it specifies on two questions: To do good? Or do it badly. After, it leads us to many channels, despite the harshness of reality, we are always reminded not to be enticed with worldly matters. Yes, life may be short, but we should use our freedom wisely. We have to be careful of our actions each day for the days are sometimes evil. A few of us know the importance of living life positively, yet, in the end; we will realize that regardless of everything that is going on, you are on your own. We make our life. This Duty reminded us that life is too short to keep on committing the same mistakes all over again. We should start making a move, whether many will hinder our path, we have to put impact on every good thing that we do. If you want your life to have an impact, you have to focus on it. Make life with less regrets, do good, be wise and strengthen your faith, brave enough to win success. At a short period stay at (NMMC) Northern Mindanao Medical Center, Medical ward, we are student nurses on action. It is where we put all of what we are in extreme preparation. You should not waste time doing senseless distractions, rather gain from your opportunities, reading, handling cases and interactions are just a few that we have mastered. Although change does not happen overnight, it is a good feeling to know that you have controlled yourself and leading it to make a difference. As our duty progresses, we have established a great bond among our group mates. We learn together, we work together and care for each other. That is the beauty in our group. We never fail to be concerned towards each other. It is more than just a group, we are family. Whatever trials, difficulties, temptation, consequences that we have right now, it serves as a reminder to trust in ourselves and our God. We should not give up. Life is great and beautiful and we realize it when we are open to learning and never are afraid to take challenges and opportunities that come along the way. One of this if we call it a trial is the challenge of making a case study on trisomy 21 disorder. Many may know if not all that this type of disorder is hard to accept in the parenting side.
DOCTOR’S ORDER
•
Jan. 10 2010 6pm BP 110/70 HR 80 RR 10 T 37
•
Jan. 11, 2010 4:30 pm BP- 100/60 HR 80 RR 20 Still with fver episodes (+) tenderness RUQ
Jan. 12, 2010 11:30 pm BP:120/80 HR:76 RR:20 Dec. poin RUQ area ↓fever episode Jan. 13, 2010 s- 1 week undocumented on and off fever with chils and nausea (+) epigastric pain •
•
Continue present meds. IVF TF: PNSS 1L @ 30gtts/min. PNSS 1L @ 30 gtts/min. Refer accordingly
•
Jan. 14 2010 9 am Pt. seen in the ward
Start_____: PNSS 1L @ 60 gtts/min_ongoing IVF TF: 1. D5NR 1l @40 gtts/min. 2. D5NR !L @ 40gtts/min. Diagnostic: CBC with pH U/A, stool exam Urea, BUN, Na, K, Alk, Phos,, SGPT, SGOT CXR: PAT UTZ: HBT Therapeutic: Paracetamol 500mg 1 tab now, then q 4 hrs for T≥38.0 Tramadol 50mg IVTT q8 hrs. Metronidazole 750 mg IVTT now, then 750 mg IVTT q 8 hrs. Ranitidine 150 mg 1 tab. BID Vit. K 1 am. IVTT now then Q 24 hr.-given 1st done Watch out for severe abdominal pain, SOB, or any unusualiies and refers to MROD Refer accordingly
Schedule for UTZ- HOT tomorrow AM pls. facilitate transport Cont. present medications IVF TT: D5NR 1L @ 20gtts/min D5NR 1L @ 20gtts/min Refer accordingly For utz of HBT today for repeat Na,K, Creat, BUN CBC with platelet Repeat PTPA-Partial Requests: 1. Cipro 7 2. Metronidazol 750 mg 3. Ranitidine 100mg 1 tab. BID 4. Tramadol 50mg IVTT q8 hr. 5. Paracetamol PRN if 38 deg. Celsius 6. Vita k 1 amp. Monitor VS q2 hr. refer if with abdominal pain and severe hypotension D5LR 1L @ 20 gtts/min x 2 cycles Refer accordingly
Continue present meds. Avoid vasalva maneuver(straining,
