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Saint Louis University School of Nursing

In Partial Fulfillment Of the Requirements For the subject NCM 108A Related Learning Experience

NURSING CARE PLAN

SUBIMTTED BY: Ambroce, Alyza Marie A. BSN 4 C4

SUBMITTED TO: EJERCITO BALAY-ODAO, RN Clinical Instructor

JANUARY 04, 2013


I.PATIENTS PROFILE:ako na bahala mgdagdag dito NAME: Lumawod, Armando Villanueva AGE: 57 SEX: Male CIVIL STATUS: Married

ADDRESS: Brgy. Nangapungan San Quintin Pangasinan RELIGION: Roman Catholic NATIONALITY: Filipino BIRTHDAY: September 28, 1955 PLACE OF BIRTH: Bacolod, Negros Occidental OCCUPATION: Caretaker DATE OF ADMISSION: December 30, 2012 TIME OF ADMISSION: 01:50 pm ADMITING PHYSICIAN: Dr. Torio ADMITTIN DIAGNOSIS: T/C Viral Hepatitis vs. Cholecystitis

II.HEALTH HISTORY: CHIEF COMPLAINT: Abdominal Pain HISTORY OF PRESENT CONDITION: 1 week prior to admission, the patient experienced abdominal pain with febrile episodes. He the went for a check-up at Pangasinan Hospital and urinalysis was made, revealing a result of UTI and reddish colored urine, the patient was then given medications such as Cefuroxime, Bromhexine HCl and Paracetamol ( drug dose is unrecalled). After 2 days of consultation, the patient returned again to the hospital for check- up and was advised for admission. During his admission, the patient was continuously observed and medications prescribed are still given. The next day after admission the patient was then referred to BEGH for transfer, medications given were: Ranitidine, Metoclopromide. Diagnostic tests were done Ultrasound which reveals tumor in the liver, CT scan which reveals Colon CA, Stage 4. Hence, the patient is admitted at present. PAST MEDICAL HISTORY: The patient does not have any history of hospitalization or surgery. FAMILY HISTORY AND PERSONAL PROFILE: The patient claims no history of DM but has a history of heart disease from the mothers side. The patient claims of alcohol drinking every night and with history of smoking .. since 16 y/o sya ngyoyosi na sya SOCIO- CULTURAL HISTORY AND ENVIRONMENTAL HISTORY: The patient works in Bacolod as a caretaker of livestock. He lives in Bacolod without his family. Prior to admission, he decided to stay in their house at Pangasinan together with his wife and childrens

III. LIST OF PRIORITIZED NURSING PROBLEMS WITH JUSTIFICATION: I used the theory of Virginia Henderson, 14 Basic Needs (Breathing, Circulation, Eat and Drink, elimination, Move and Maintain posture, Sleep and Rest, Undress and Dress, Maintain body temperature, Keep Clean, Avoid danger, Communication, Work, Worship, Play and Learn) to prioritize patients identified problems. NURSING DIAGNOSIS CLASSIFICATION OF PROBLEM 1. Acute Pain related Actual This is the first prioritized JUSTIFICATION

to tension in the walls of abdomen secondary to Abdominal distention

problem because pain is a subjective data that only the patient can tell, according to ER books, it is considered as the 5th vital sign and this must be addressed immediately

2. Ineffective Airway Clearance related to retained bronchial secretions 3. Impaired gas exchange related to ventilation perfusion imbalance secondary to altered oxygen capacity of the blood 4. Urge urinary incontinence related to tissue trauma secondary of IFC insertion

Actual

This is the second prioritized problem. The patient is on 02 inhalation 1.2LPM/NC, crackles are heard on lower lung fields.

Actual

This is the third problem since it has something to do with perfusion. This s supported by prolonged capillary refill during assessment.

Actual

In Hendersons 14 basic needs eliminating body wastes was ranked 3rd. The insertion of IC caused trauma to the urethra and it also relaxed the sphincter which then caused the difficulty I urination control

5. Activity Intolerance related to restricted mobility

Actual

In Hendersons 14 basic needs, moving and maintaining desirable position is ranked as the fourth, Patient has limited movement because of abdominal pain.

6. Fatigue related to altered physical mobility 7. Impaired skin integrity related to tissue trauma secondary to IFC insertion

Actual

Fatigue is also felt by patient because of the abdominal pain he is experiencing. In Hendersons 14 basic needs, keeping the body clean is important. The patient skin is disrupted, therefore there is also destruction of skin layers and invasion of body structures

Actual

8. Risk for Infection related to tissue trauma

Potential

According to Henderson ,the body must be clean and well groomed and it must be free from any infection. Since the patient has IFC and IV line he is prone of having infection

Kulang pa la toh ng seld care deficit tpos constipation tpos disturb sleeping pattern tpos impaired breathing pattern, tpos ung sa nutrition niya

JANUARY 01, 2013 PROTHROMBIN TIME:

PROTHROMBIN TIME INR

RESULTS 19 1.57

NORMAL VALUES 10-17 seconds 1-2

JANUARY 03 2013 RESULTS 67 0.89 0.20 NORMAL VALUES MALE: 135-180 g/L 0.51-0.67 MALE: O.40-0.54 %

HEMOGLOBIN LEUKOCYTES ERYTHROCYTE

DECEMBER 31, 2012 URINALYSIS: Color: orange Mucous thread: few Urates: moderate Reaction: 5.0 Specific gravity: 1.020 Transparency: slightly turbid

DECEMBER 31, 2012 ULTRASOUND: Results: Normal Pancreas, Spleen and Kidneys. Hepatic nodules primary vs. Metastasis Bile gravel suggest correlation with CT Scan JANUARY 01, 2013 COMPUTED TOMOGRAPHY SCAN:

Conclusion: Enhancing irregular ceca and ascending colon masses, consider malignancy multiple partially enhancing hepatic tumors, probably metastasis correlate CT findings with other imaging modalities like colonoscopy and barium enema, biopsy also suggested, if still clinically indicated DECMBER 30, 2012 X-RAY: Results: True or Apparent Cardiomegaly elevated Right hemidiaphragm DECEMBER 31, 2012 RESULTS 197 211 397 NORMAL VALUES 9.0-48 u/L 5.0-49 u/L 40-150 u/L

SGOT/AST SGPT/ALT ALP

DECMBER 30, 2012 RESULTS 4.36 66 NORMAL VALUES 2.50-6.50 62-132

BUN CREATININE

DECEMBER 31, 2012 RESULTS 130.7 3.9 95.8 NORMAL VALUES 135-148 3.5-5.3 98-107

SODIUM POTASSIUM CHLORIDE

JANUARY 02, 2013 Anti HAV- IgM Result: 0.328 non-reactive AFP (Cobas e411)- Electrochemiiluminiscence Assay Result 159 iu/m Normal value:0.0-5.80

CORAS e4m Analyzer Result: 0.773 ng/ml Normal value: 0.00 4.70 ng/ml

JANUARY 01, 2013 RESULTS 6.76 7.28 3.29 NORMAL VALUES 3.6-6.10 mmol/L 3.07-7.25 mmol/L 0.4-1.81 mmol/L

FBS TOTAL CHOLESTEROL TRIGLYCERIDE DECEMBER 30 2012 X-RAY:

Lungs are hypocierated, heart appears enlarged Right hemidiaphragm is increase, bones are intact True or Apparent Cardiomegaly elevated Right hemidiaphragm MEDICATIONS: VITAMIN K KETOROLAC REGULAR INSULIN for CBG >180 mg/dl D5050 for CBG of < 80 mg/dl TRAMADOL CEFTRIAXONE OMEPRAZOLE PARACETAMOL

NCP 1: Acute Pain related to tension in the walls of abdomen secondary to Abdominal distention

ASSESSMENT S> Masakitpadinyongtiyanko patient rated pain as 8/010, burning in characteristic, it is not radiating, aggravated when moving and relieved by sleeping. O> irritable when in pain >with moist and warm skin touch > with limited movement >needs total assistance in moving >muscle strength of 4/5 in both upper and lower extremity. >with guarding behavior noted over the abdomen >with grimacing noted when moving >with distended abdomen >with abdominal girth of 97. 5 cm >with normoactive bowel sounds >with pain medication of Ketorolac IV

EXPLANATION OF THE PROBLEM Abdominal pain is pain that is felt in the abdomen. The abdomen is an anatomical area that is bounded by the lower margin of the ribs and diaphragm above, the pelvic bone (pubic ramus) below, and the flanks on each side. Although abdominal pain can arise from the tissues of the abdominal wall that surround the abdominal cavity (such as the skin and abdominal wall muscles), the term abdominal pain generally is used to describe pain originating from organs within the abdominal cavity. Organs of the abdomen include the stomach, small intestine, colon, liver, gallbladder, spleen, and pancreas.Abdominal pain is caused by inflammation, distention of an organ, or by loss of the blood supply to an organ.

OBJECTIVES STO: After 4-6 hours of nursing intervention, the pain felt by the patient will decreased from 8/10to 6/10 by doing nonpharmacological methods to help control pain such as DBE and doing diversional activities LTO: After 3 days of nursing intervention Patient will rate pain as a 2/10 or less at the time of discharge and will be sent home on low dose oral pain medications.

NURSING INTERVENTIONS

RATIONALE

EVALUATION

Monitor Vital Signs

To obtain baseline data. Changes in these vital signs often indicate acute pain and discomfort To have a necessary data about pain felt by the patient

Assess pain scale, location, characteristic, onset, duration, frequency, and precipitating factors of pain Observe for non verbal cues of pain

To evaluate severity of pain

Provide opportunities for rest by promoting less environmental stimulation

Rest can decreases discomfort thus restores the energy of the patient Relaxation techniques promotes comfort to patient and to refocus attention

Reference: MS by Black 7th edition Scrib.com

Perform and demonstrate relaxation technique such as deep breathing exercises.

Facilitates the comfort of the

patient Promote bed rest in a comfortable position

Change the position of the patient frequently

Promotes comfort and prevention of bed sore

Administer fluids, medicines and blood products as ordered

Aids in maintaining adequate circulating volume and to help maintain necessary body functions as the action of drug works

NCP 2: Risk for Infection related to tissue trauma A E ON RE SXBUAV SPJ RT A ELESI L S ACI OU SNT NNA MA I GA T ETV LI NI EI EO T OS N N N T E O R F V E T N H T E I O P N R S O B L E M S SBT MC > e O o h c : n a a

Encourage patient to verbalize concerns

Reduction of anxiety promotes comfort

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