Presented to the STI College Global City College of Nursing In Partial Fulfillment of the requirement in the Subject Head

Nursing Practice Bachelor of Science in Nursing

Case Presentation Liver Abscess

Gamotin, Trixie Anne G. Poblete, Justine L. Roldan, Lynette _______________________________ Level IV BSN Students Group 5

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TABLE OF CONTENTS

i.

Title

Page

1 ii. Table of Contents

. 2 iii. Acknowledgements . 3 iv. Introduction .. 5 v. Objectives ... 7 vi. Biographic Data

.. 8 vii. Nursing History

9 viii. Gordons Pattern of Healthcare

.. 11

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ix.

Physical

Assessment

16 x. Laboratory Studies/Diagnostic Studies

.. 18 xi. Medications .. 23 xii. Anatomy and Physiology

. 34 xiii. Pathophysiology 36 xiv. Nursing Care Plan a) Actual . 38 b) Risk . 41 c) Wellness . 43 xv. Evaluation of Case Presentation

.. 44

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ACKNOWLEDGEMENTS The success of this case presentation has been made possible by the invaluable help of the following: Our almighty God for His divine guidance and the knowledge He bestowed upon us. STI College Global City - College of Nursing, for giving the students the opportunity to experience this related learning. Through this study we gained numerous knowledge, experience and insights. Tondo Medical Center Hospital &its Staff, for allowing us to interview, render care to our client and giving us access to study & review clients chart. The patient, for his invaluable help by providing the presentors all the essential data and informations that they need for case presentation as well as the trust that the nursing students will keep anonymity of his identity. Dr. Miguel E. Mangada, Dean of STI College Global City of Nursing for the guidance, for believing in our capabilities and for inspiring the groups to be more productive student nurses and citizen of the country. Mr. Rudy Anthony Reyes and Mrs. Corazon Duran, the groups clinical instructors for their support and advices they have given them, for all the word of encouragement, and for sharing their knowledge and most especially for believing in the strengths and capabilities of the entire class Ms. Marison Magpantay, the groups adviser for the support and

contributions not merely with the case study but also for sharing her knowledge. The rest of the faculty, for giving their free assistance and sharing their knowledge as the group this case presentation

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To the presentors parents, for providing financial support for showing their unending love and care to all the groups endeavors is to each and every one member of the presenters, As we realized that as we took Nursing as our future profession we thank you for the cooperation and understanding each has shown for the completion of this task. And to those whom we havent mentioned, the humblest gratitude of the group are yours.

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INTRODUCTION Liver abscess is a pus-filled cyst in the liver.The liver abscess has a thin capsular wall with a necroticcentre composed of a thick fluid. Typically,abscess fluid is odourless, resembling chocolate syrup oranchovy paste in half, and bacteriologically sterile, althoughsecondary bacterial invasion may occur.

The liver is an organ in the digestive system that assists the digestive process and carries out many other essential functions. These functions include producing bile to help break down food into energy; creating essential substances, such as hormones; cleaning toxins from the blood, including those from medication, alcohol and drugs; and controlling fat storage and cholesterol production and release.

The condition can be caused by infections spread directly from nearby structures, such as the bile-draining tubes, from the appendix or intestines, or carried in the bloodstream from more distant parts of the body.It can also develop as a result of surgery or other trauma to the liver.

Liver abscess is usually treatable and often can be cured with a course of antibiotics or a combination of antibiotics and a surgical procedure to drain the abscessdepending on the size, number, and complexity of the abscess(es) such the following cases:

a) Abscess with intra-abdominal pathology requiring surgery b) Ascitis

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c) Multiple large abscesses d) Abscess which cannot be drained percutaneously

If Left untreated, however, a liver abscess can burst and spread the infection, leading to sepsis, a life-threatening bacterial blood infection.

ETIOLOGY The 3 major forms of liver abscess, classified by etiology, are as follows:

Pyogenic abscess, which is most often polymicrobial, accounts for 80% of hepatic abscess cases in the United States.
o

Maybe of biliary portal, arterial, or traumatic origin Ascending infection of the biliary tree secondary to obstruction is now the most identifiable cause of PLA.

Etiology of biliary obstruction geographical diffrence Western countries this scenario is common in patients with malignant disease (Tumors) Asia, gall stone disease and hepatolithiasis are more common.

Amebic abscess due to Entamoebahistolytica accounts for 10% of cases.

o o o

considered in endemic area (naturally present in the area) Usually single and mostly found in the rightlobe of the liver. Koch describe amoeba as the cause of liver abscess

Fungal abscess, most often due to Candida species, accounts for less than 10% of cases.

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Liver abscess is usually treatable and often can be cured with a course of antibiotics or a combination of antibiotics and a surgical procedure to drain the abscess depending on the size, number, and complexity of the abscess.

If Left untreated, however, a liver abscess can burst and spread the infection, leading to sepsis, a life-threatening bacterial blood infection.

OBJECTIVES General objective This case presentation was designed to develop a holistic and patient centered nursing care and responsibilities. This is to broaden the knowledge of the presenters as well as the audience with regards to Liver Abscess; this is also designed to enhance skills and attitudes in the application of nursing process and management of the disease.

Specific objectives

1. For the participants/critics, for us presenters & significant others to have a better understanding on the disease process. 2. To have the pathophysiology and to trace the occurrence of Liver abscess. 3. To utilize properly the nursing process (assessment, diagnosis, planning, intervention, evaluation) as the framework for the care of the patient.

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4. To learn various medications, its condition, adverse effects & accompanying nursing responsibilities. 5. To put into action what we have learned in the school (such as nursing process) and apply our knowledge in providing quality and individualized nursing care. 6. To enhance groups attitude, like discipline, cooperation, leadership abilities and teamwork in making and presenting a case presentation.

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BIOGRAPHIC DATA

Name: Address: Age: Sex: Religious Affiliations: Occupation: Marital Status: Room & Bed number: Admission: Chief Complaint: Diagnosis: Attending Physician: Hospital:

Mr.JLT 19-F Aquino St. Nilungan, City of Malabon 50 years old Male Roman Catholic Construction Worker (Contractual) Married Male Gastro, Medicine Ward January 24, 2013/5:30PM Severe Stomach ache and vomitting Liver Abscess Dr. N.P. M.D Tondo Medical Center North Bay Boulevard, Balut, Tondo, Manila

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NURSING HISTORY

1. History of Present Illness: Prior to admission the patient experienced severe stomach ache at right lower quadrant of the stomach accompanied with vomiting. Patient verbalized that the pain is cramp-like; the duration of the pain comes strongly for a while and then lessens its intensity for a while and the pain gets triggered and become worse after eating. Vomitus of the patient is clear and water like. 2. Family History of Illness

GRANDFAT HER HYPERTENSI ON

GRANDMOTHE R HEART ATTACK

GRANDFAT HER UNKNOWN

GRANDMOTHE R UNKNOWN

MOTHER HYPERTEN SION FATHER TUBERCU LOSIS

BROTHER 53 HYPERTENS ION

MR. JLT 50 LIVER ABSCE SS

SISTER 45 BREAST CA

BROTHE R 42 VEHICU LAR ACCIDE NT

BROTHER 39 HYPERTEN SION

LEGEND
ALIVE LIVER ABSCESS DECEASED Page 12

3. Childhood Illness: The patient suffered from seasonal cough and colds as well as fever during younger years.

4. Hospitalization history: Patient had past operation when he was 17 years old. He had cholecystectomy.

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GORDONS PATTERN OF HEALTHCARE Activities of Daily Livings 1. Health Perception Health Management Pattern Before Hospitalization Bago ako maospital hindi ako ganun kaalaga sa sarili ko. Kapag nagkakasakit ako, yung mga lagnat at sipon o kya konting sakit ng tyan lang hindi ko na pinapansin. Hinahayaan ko nalang at pinapalipas hanggang sa mawala. During Hospitalization Ngayon na naospital na ako natuto nako ng leksyon, mabuti ng gamutin agad yung mga simpleng sakit kase kapag napabayaan lalong mahirap gamutin. Yung simpleng sakit kc kaunting pera lang ang mauubos at malaki ang posibilidad na gumaling, pag pinapatagal lalo lang nagiging magastos at mahirap. Malakas akong Ngayong naospital kumain pero hindi ako, humina ako naman ako mahilig kumain kasi lage sa baboy, wala ako walang gana, kasi kming pambili di kasi ganun non. Madalas kong kasarap ang kainin ay isda, pagkain dito sa hindi rin ako ospital at saka masyadong sumasakit ang tyan mahilig sa gulay. ko kapag Nakakadalawang napapadami ang kuha ako ng kanin kain ko. Halos kada kain dalawang subo pa lang wala na ako gana. Tuwing umaga Nahihirapan ako sanay talaga ako mapadumi dito sa na ospital,naninibago dumudumi,madala siguro ako, pero s pagkagising ko. palage padin Mga alas-singko ng naman ako umaga Interpretation and Analysis Hospitalization affects the health perception and management of the patient. The client became more conscious with his health and learned that even simple diseases can worsen and threaten his life. He became more conscious with regards to medical treatments that he needs.

2. Nutrition Metabolic Pattern

Nutrition metabolic pattern of the patient has been affected due to the different taste of food served to him on the hospital and at home. Too much eating also affects his condition so he is limiting his self with regards to foods he eat.

3. Elimination Pattern

Elimination pattern of the patient was affected; contributing factors includes the change in Page 14

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4. Activity Exercise Pattern

5. Sexuality Reproductive Pattern

napapadumi hindi nga lang arawaraw. Hindi ko na matandaan kung kada ilang araw, kada ikalawang araw yata. Isang beses lang sa isang araw ako napapadumi. Yung pag ihi ko naman mayat maya kasi inom din ako ng inom ng tubig maganda din daw kasi yun para sa akin. Hindi ako Ngayong naospital nageehersisyo sa ako natutunan ko bahay, hindi ko na ang kasi iyon kahalagahan ng nakasanayan. pageehersisyo Nakakapaglakadkahit siguro lakad ako paglalakad arawkapagbibili ako ng araw. Natatakot pandesal sa kasi ako subukan labasan naming na magjogging kasi pang almusal. bka lalo bumuka etong tahi ko sa tyan. Patient refused to give/share information

umaga. Madalang akong umihi dahil hindi ako palainom ng tubig

environment he is not used to defecate on other toilets and the decrease food intake of the patient.

6. Sleep Rest Pattern

Sa bahay naming maaga talaga kaming natutulog, alas otso o alas nwebe natutulog na talaga ako.

Hirap akong matulog dito sa ospital, sa gabi halos tatlong oras nga lang ang tulog ko kasi pagising-

The client became aware of the importance of exercise for his health upon hospitalization and planned to practice that at home. His hospitalization helped him realize the significance of exercise to his health. Client is not open to talk about his Sexual and reproductive pattern because for him it should be private between him and his wife. Sleep and rest pattern of the patient was altered upon hospitalization due change in the Page 15

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gising ako. Naninibago siguro ako. Pero merong pinapainom na gamut sa akin na nakakaantok. Pag iniinom ko yun kahit tanghaling tapt inaantok ako.

7. Cognitive Peceptual Pattern

Di pa naman ako makakalimutin. Kilala ko pa naman lahat ng kasama ko sa bahay.

Ewan ko ba, epekto siguro ng gamot, kailangan pa kasi ipaalala lage sakin ng misis ko na kailangan ko uminom ng gamut. Nalilito kasi ako sa mga angalan ng tabletas. Yung mga pangalan naman wala nagbago alam ko pa din ang pngalan ng mga anak ko.

8. Role Relationship Pattern

Maayos naman ang samahan namin ng asawa at mga anak ko. Nahihiya nga ako sa asawa ko at mas malaki ang kita nya kesa sa akin. Halos siya na nga ng

Ngayong naospital ako alam ko na mas tumatag ang samahan naming ng asawa ko at nakita ko ang pagpapahalaga sakin ng mga anak ko. Nahihiya nga langako kasi

environment. The medications that he I taking also affects his sleeping pattern. Diphenhydramine is one of his medications and one common side effect of this is sleepiness. The client is confused with regard to the time of medication. His cognitive pattern was also slightly affected, he denies this because for him hes still able to recite his childrens names and remember thing that happened in the past but considering the question regarding his elimination pattern in the hospital. He already forgot the last day of his bowel elimination. Prior to hospitalization the client has already a problem with regards to role pattern because he is guilty that his wife seems to be the bread winner of the family because Page 16

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nagtatrabaho para sa pamilya namin pero di namin pinag-aawayan yun. Bago ako maospital tulungan kme sa gastusin sa bahay.

9. Self Perception / Self Concept Pattern

nagging pabigat pa ako dahil kailangan pa nila akong bantayan dito sa ospital at hindi ako makatulong sa pinansyal dahil di ako makapagtrabaho. May gawa pa naman kami sa construction ngayon. Nung hindi pa ako Hindi naman ito ngakakasakit di ang unang beses ako madalas mag- na naospital ako, alala sa sarili ko. pero ngayon naisip Mas mahalaga ko na na kailangan yung pamilya ko. ko alagaan ang Sa katunayan nga sarili ko dahil kahit ngakakasakit tumatanda na din ako pinipilit ko na ako. Kung makasideline sa babalewalain ko trabaho para ang sakit ko at magkapera para sa lalong lalala pangastos namin. nakakaawa naman Madami na din ang pamilya ko. mga pinagdaanan Mas lalo kong ko sa buhay. Alam napatunayan na ko naman na nagging mabuti nagging akong padre de makabuluhan pamilya dahil di buhay ko. ako pinapabayaan Napagtapos ko ang ng asawa at mga mga anak ko kahit anak ko dito sa hayskul at napalaki ospital ko sila ng maayos. Kahit construction worker lang ako araw-araw din naman kme nakakakain ng tatlong beses dahil sa pagtutulungan

of the small income that he contributes to the family and upon hospitalization his feeling of guilt upon his role worsen because supposibly he is working but due to his illness he cant go to his work. The client learns to appreciate his self and give importance to his health rather than the first time he has been hospitalized. He realized that he fulfilled hes role as a father and husband because his wife and sibling doesnt leave him alone.

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10.Coping Stress Tolerance Pattern

naming ng asawa ko Hindi naman ako madalas mapagod dahil contratahan lang naman ang trabaho ko. Pag may trabaho sa construction itinutulog ko nalang ang pagod ko o kya manonood ng TV.

11.Values Belief Pattern

Hindi naman ako napapagod dito kasi magdamag na nakahiga lang naman, naiinip na nga ako eh.Inaaliw ko nalang ang sarili ko sa pakikipagkwentuha n sa misis ko. Wala naman kasing TV ditto. Hindi ako Sa paglabas ko palasimba na tao. siguro dito sa Pero nagdadasal ospital e din naman ako. magsisimba na ako Hindi kami katulad para ng ibang pamilya makaagasalamat na sama-sama sa Diyos. Kung nagsisimba tuwing tutuusin kasi pang lingo kasi may tatlong buhay ko pamilya na din na to kasi dib a yung dalawa kong naoperahan na anak. Naniniwala ako. Eto pa din ako, din ako sa mga buhay pa din. albularyo, pag yata Patuloy pa din ang mahihirap dun una pagkonsulta ko sa lumalapit albularyo. Wala naman masama kung maniwala ako e.

The client has changed his way of coping but still prefer watching TV to relieve his stress.

His belief in prayers and in God became stronger upon hospitalization. He also believe in herbularyos.

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PHYSICAL ASSESSMENT Date performed: days 1. Vital signs: a. b. c. d. January 28, 2013 No. of hospital Days: 4

Temperature: 37.9C Pulse Rate: 71 bpm Respiratory Rate: 24 cpm Blood pressure: 120 / 80 mmhg

2. Regional Examination: Regions of the body a. Hair

Methods of Assessment (IPAP) Inspection / Palpation

Results Evenly distributed hair, smooth, without dandruff, black in color, no infection or infestation of parasite. Rounded and smooth, no wounds, (-) masses Symmetrical in shape, centered head position Symmetrical, eyelashes are evenly distributed and pale conjunctiva, yellowish sclera, PERRLA. (+) mucus discharge, able to smell, no lesion, no nasal flaring. Gums: slightly reddish in color, wearing full dentures up and down, pinkish tongue, (-) swelling throat. No masses present, flexible and movement of the head equally both sides, supported by pillows. Symmetric, (-) fractures, heart rate heard at mid clavicular space at 4th intercostals space (71bpm), (+) crackles (-) fracture, spine is aligned, uses of accessory muscle like scalene when Page 19

b. Head c. Face d. Eyes

Inspection / Palpation Inspection / Palpation Inspection / Palpation

e. Nose

Inspection / Palpation

f. Mouth and pharynx

Inspection

g. Neck

Inspection / Palpation

h. Chest wall ( Anterior)

Inspection / Palpation / Auscultation

i. Chest wall (Posterior)

Inspection / Palpation / Auscultation

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j. Breast and Axilla k. Heart l. Abdomen

No assessment done. Auscultation Inspection (patient refused to auscultate, percuss andpalpate his stomach due to pain)

breathing. No assessment done. (-) arrythmias Rounded, bloated, shiny, (+)evidence of enlargement of liver, 6inches scar on right quadrant of the stomach noted, penrose drainage noted at right quadrant of the stomach, hair is well distributed. Skin: jaundice complexion, evenly distributed hair on extremities, presence of sweat at times. Nails: yellowish nail bed, thick, hard, rounded Capillary Refill: 2-3 secs. No assessment done. Warm to touch, wasnt able to freely move lower extremities due to radiating pain from the abdomen Warm to touch, wasnt able to freely move upper extremities due to radiating pain from the abdomen Dark orange urine, no foul odor

m. Skin and nails

Inspection

n. Anus and Rectum o. Extremities (lower) *include ROM and muscle strength

No assessment done. Inspection

p. Extremities (upper) *include ROM and muscle strength

Inspection

q. Urinary

Inspection

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LABORATORY STUDIES/DIAGNOSTIC STUDIES BLOOD CHEMISTRY TEST NAME RESULT INTERPRETATION NORMAL RANGE ANALYSIS

HDL CHOLESTEROL

0.187

1.03-1.55 mmol/L

carry cholesterol through the blood

57.1 AMYLASE

NORMAL

20-110U/L

CHOLESTEROL

3.57

NORMAL

3.5-5.7mmol/l

GLUCOSE

5.19

NORMAL

3.9-5.22mmol/l

TRIGLYCERIDES

1.58

NORMAL

0.5-1.04mmol/

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TEST NAME DIRECT BILIRUBIN 108.9

RESULT

INTERPRETATION

NORMAL RANGE 3.4-13.8 umol/l

ANALYSIS Conjugated bilirubin is another name for direct bilirubin. Bilirubin concentrations are elevated in the blood either by increased production, decreased conjugation, and decreased secretion by the liver, or blockage of the bile ducts. In cases of increased production, or decreased conjugation, the unconjugated or indirect form of bilirubin will be elevated. Unconjugated bilirubin is another name for indirect bilirubin Serum glutamic oxaloacetic transaminase, an enzyme that is normally present in liver and heart cells. SGOT is released into blood when the Page 22 liver is damaged. The blood SGOT levels are thus elevated with liver

INDIRECT BILIRUBIN

113.1

0-10umol/l

SGOT 49.26 Serum glutamic oxaloacetic transaminase or Aspartate transaminase (AST) LIVER ABSCESS

9-48u/l

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TEST NAME

RESULT

INTERPRETATION

NORMAL RANGE

ANALYSIS

Hemoglobin

111

120-170g/l

Hematocrit

0.339

0.40-0.57

RBC

3.27

4.5-6.0

Lympocytes

0.164

0.20-0.40

MCHC(mea 32.6 n corpuscula r hemoglobi nLIVER ABSCESS concentrat ion)

33.0-37.0

The hemoglobin molecul es with the help of external chemical factors take up oxygen molecules in the lungs and then send them to the various tissues of our body. Hematocrit is the measure of how many red blood cells there are in the blood. This number is tested by taking a sample of blood. The result is given as a percentage. The main function of the red blood cell is to transport oxygen from the lungs, to the other tissues and cells of the body A lymphocyte is a type of white blood cell present in the blood. White blood cells help protect the body against diseases and fight infections. Mean corpuscular hemoglobin concentration (MCHC) is the average concentration of hemoglobin Page in red24 blood cells. MCHC is used to help diagnose the type (cause) and

WBC

26.3

4.6-10

SEGMENTER S

0.779

0.50-0.70

They fight infections in a process known as phagocytosis where they surround the foreign organisms and destroy it. it means that theres a presence of infection Segmenters (segmented neutrophils, are one of the types of neutrophils, which are the most common type of white blood cells.

DIAGNOSTIC EXAM CHEST PA RESULT: NO ACTIVE PARECHYMIAL INFILTRATES HEART IS NOT ENLARGED BLUNTED RIGHT COSTOPHRENIC SULCI IMPRESSION: PLEURAL THICKENING VS MINIMAL PLEURAL EFFUSION, RIGHT.

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DRUG ORDER

MECHANISM OF ACTION

INDICATIONS

CONTRAINDIC ATIONS

ADVERSE EFFECTS OF THE DRUG Peripheral neuropathy, manifested as numbness and tingling in hands or feet, is usually reversible if treatment is stopped immediately after neurologic symptoms appear. Seizures occur ocassionally.

NURSING RESPONSIBILIT IES/ 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 doctors 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 IVT route according to the doctor R> Follow the doctors order. Question for hypersensitivity on Page 26 metronidazole R> to determine if the med is

Generic name: Metronidazol e Brand name: Metronidazol e Benzoate Classification : Antibacterial, antiprotozoal Dosage: 500mg/vial 1vial every 8hrs. TIV ANST(-)

A nitroimidazole derivative that disrupts bacterial and protozoal DNA, inhibiting nucleic acid synthesis. Therapeutic Effect: Produces bactericidal, antiprotozoal, amebicidal, and trichomonacidal effects. Produces antiinflammatory and immunosuppres sive effects when applied topically.

For treatment of anaerobic infection (skin and skin structures, lower respiratory tract.

Hypersensitivity to other nitroimidazole derivatives.

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DRUG ORDER

MECHANISM OF ACTION

INDICATIONS

CONTRAINDICATIO NS

ADVERSE EFFECTS OF THE DRUG

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 clients response to the med. Do not take with antacids R> since it could reduce or destroy the drugs effectiveness.

Generic name: Ciprofloxacin hydrochloride Brand name: Ciloxan

inhibits the enzyme DNA gyrase in susceptible bacteria, interfering with bacterial cell replication. Therapeutic Effect: Bactericidal

For treatment of infections due to, S. typhi including intraabdominal, and lower respiratory tract.

Cautions: renal impairment, CNS disorders, seizures, those taking caffiene.

Classification: Anti-infective

Dosage: 500mg/tab 1tab BID

Superinfection, 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.

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Dug Name Generic Name: Mupirocin ointment >Bactroban

Mechanism of Action It kills sensitive bacteria by stopping the production of essential proteins needed by the bacteria to survive.

Indication Traumatic skin lesions infected with staphylococcus aureus or pyogenes

Contraindicatio n allergic to any ingredient in Mupirocin Ointment

Adverse Effects >Burning >pain >stinging >Severe allergic reactions (rash; hives; itching; -rash >severe itching

Drug Classification: Antibacterial Topical

Dosage: Apply in wound site RUD every 8hrs.

Nursing Interventions Mupirocin Ointment is for external use only. Do not get it in your eyes or mouth. Long-term or repeated use of Mupirocin Ointment may cause a second infection. Apply a small amount of Mupirocin Ointment 3 times a day. Wash and completely dry the affected area. Gently rub the medicine in until it is evenly distributed. The affected Page 29

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area may be covered with gauze or a bandage. To clear up your infection completely, use Mupirocin Ointment for the full course of treatment. Keep using it even if you feel better in a few days. Wash your hands immediately after using Mupirocin Ointment.

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Dug Name

Generic Name: ceftriaxone Brand Name: Forgram Classification: Cephalosporins Dosage: 1gram/vial 2vials OD TIV

Mechanism of Action INDICATIONS: Inhibits cell-wall Treatment of synthesis,promoting infections of the lower osmotic resp tract, skin & skin instability;BACTERIACI structure infection, DAL. intra-abdominal infections.

Indication

Side Effects/ Adverse Effects Pain Phlebitis Rash Diarrhea Thrombocytosis Leucopenia Respiratory superinfections

Nursing Considerations Assess patients previous sensitivity reaction to penicillin or other cephalosphorins. Assess patient for signs and symptoms of infection before and during the treatment Obtain C&S before beginning drug therapy to identify if correct treatment has been initiated. Assess for allergic reaction. Assess for possible superinfection: itching fever, malaise, redness, diarhhea

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Medication

Classification/Act ion

Indication s Relief of allergic sympto ms Night time sleep aid Active and prophyl actic treatme nt of motion sickness Cough due to colds.

Contraindicati ons Contraindicat ed with allergy or hypersensit ivity to any antihistamines, third trimester of pregnancy and lactation. Use cautiously with narrowangled glaucoma, stenosing peptic ulcer, prostatic hypertrophy, asthmatic attack, bladder neck obstruction, pyloroduode nal obstruction.

Side Effects

Adverse Effects anaphyla ctic shock

GENERIC NAME: Diphenhydram ine Hydrochloride BRAND NAME: Benadryl USUAL DOSAGE/ FREQUENCY: 1 Ampule Now TIV DATE:1/28/13

Classification: Antihistamine Anti-motion sickness Action: Competitively blocks the effects of histamine at H1 receptor-sites, has atropine like, antipruritic and sedative effects.

Drowsines s, sedation, disturbed coordinati on headache & dizziness constipati on epigastric distress thickening of bronchial secretions palpitation s dryness of nasal mucosa

Nursing Responsibili ties Assess the patient for any history of allergy to the drug, certain medical condition and history that may affect the potency or even produce opposite effect when given. Administer with food if epigastric discomfort occurs. Monitor patients response and arrange for adjustment of dosage to lowest possible Page 32

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effective dose. Instruct patient to avoid the use of alcohol, serious sedation may occur. hallucinations , tremors, loss of coordination, unusual bleeding or bruising, visual disturbances and irregular heart beats.

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DRUG

CLASSIFICA TION

ACTION

DOSAGE

INDICATIO N

CONTRAINDICA TION

ADVERSE REACTIO N Hydroxyzi ne can cause side effects that may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be awake and alert. Stop using hydroxyzi ne and call your doctor at once if you have a serious side effect such as tremors, confusion, seizures, or restless muscle movemen ts in your eyes,

NURSING RESPONSIBIL ITY Take this medicine with a full glass of water. Seek emergency medical attention if you think you have used too much of this medicine. Overdose symptoms may include extreme drowsiness, nausea, vomiting.

Generic Name: Hydroxyzin e Brand names: Ata rax

First Generation AntiHistamine

Hydroxyzin e reduces activity in the central nervous system. It also acts as an antihistami ne that reduces the natural chemical histamine in the body. Histamine can produce symptoms of sneezing and runny nose, or hives on the skin.

10mg /tab Give 1tab now. Date:1/31/1 3

Hydroxyzine is also used to treat allergic skin reactions such as hives or contact dermatitis. Hydroxyzine is used as a sedative to treat anxiety and tension. Hydroxyzine may also be used to control nausea and vomiting.

Contraindicated in patients hypersensitive to drug

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DRUG

CLASSIFICATIO N

ACTION

DOSAGE

INDICATION

CONTRAINDICATIO N

ADV REA

Generic Name: Paracetam ol Brand Name: Biogesic

It belongs to a class of drugs antipyretics (fever reducers).

It. It reduces fever through its action on the heatregulating center of the brain. Specifically, it tells the center to lower the body's temperatur e when the temperatur e is elevated.

1tab every 4hrs. For temperatur e 37.7/c And up.

It is used to bring down a high temperature (fever)

Contraindicated Hypersensitivity to drug Use cautiously in patients with any type of liver dse.

Side are S rashe blood disor and a inflam n of t panc have occa y occ in pe takin drug regu basis long

ANATOMY AND PHYSIOLOGY ANATOMY OF THE LIVER The liver is the largest organ in the body, normally weighing about 1.5kg (although this can increase to over 10kg in chronic cirrhosis). The liver is the main organ of metabolism and energy production; its other main functions include:

Bile production Storage of iron, vitamins and trace elements detoxification conversion of waste products for excretion by the kidneys

Gross Anatomy The liver is divided into 4 lobes: 1. Right 2. Left 3. Caudate 4. Quadrate LIVER ABSCESS Page 36

Falciform ligament separates the right and left lobes. Round ligament-inferior to the falciform ligament which protrudes from the liver slightly Gallbladder- most inferior portion of the right lobe Caudate lobe is located superiorly,approximately between the right and left lobes Sulcus for the inferior vena cava - Adjacent to the caudate lobe Portahepatis, where the hepatic artery and hepatic portal vein enter the liver Portal vein carries nutrient laden blood from the digestive system. Hepatic artery distributes blood to the liver, pancreas and gallbladder as well as to the stomach and duodenal portion of the small intestine. Hepatic vein, where post-processed blood leaves the liver, is found inferior and adjacent to the sulcus for the inferior vena cava. Bile duct which leads back to the gallbladder.

Microscopic The basic functional unit of the liver is the liver lobule. The primary structures in a lobule include: Plates of hepatocytes form the bulk of the lobule Portal triads at each corner of hexagon Central vein Liver sinusoids that run from the central vein to the portal triads Hepatic macrophages (Kupffer cells) Bile canaliculi (little canals) formed between walls of adjacent hepatocytes Space of Disse a small space between the sinusoids and the hepatocytes Cell Types

1. Hepatocytes Blood flowing toward the hepatic vein within the space of Disse passes both exposed surface areas of the hepatocyte plates, and toxins and nutrients within the blood are extracted by the hepatocytes. 2. Kupffercells are macrophages that reside in the sinusoids. These cells help clear out old red blood cells and bacteria. They also break down heme (the iron-containing pigment in hemoglobin) into bilirubin, which then becomes one of the chief pigments of bile. 3. Sinusoidal endothelial cells are fenestrated (Latin for windows), meaning they have large pores that allow most proteins to pass freely through the sinusoidal endothelium into the space of Disse, where they LIVER ABSCESS Page 37

can make direct contact with hepatocytes. The pores are also bidirectional, meaning that proteins created by the liver and other substances stored or processed by the liver can also be passed back into the blood. 4. Ito cells are found in the space of Disse. They are important because when the liver is injured, the Ito cells transform into cells that produce collagen, which leads to liver fibrosis. If this occurs on a large scale, it can lead to cirrhosis of the liver. 5. Bile duct epithelial cells line the interlobular bile ducts within the portal triads.

Pathophysiology Predisposing Factors: Pet/ Animal in home Homosexual ( Anal- oral transmission)

Precipitating Factors: Chronic Alcoholic Tropical Areas

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Entamoebahistolytica cyst might ingested

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Trophozite survives acidic stomach CC: Severe stomach pain and vomiting Attachment to cecal mucosa and penetration of epithelium by lytic digestion Invades to mesentery toward portahepatis Hepatic Tissue Injury

Jaundice

Dolor (Pain) RUQ

Diversion Deep breathing exercise

Kupffer cells & more leukocytes attacked the invading trophozite WBC 26.3/4.610 Pyrogen release

Pus Formati Hepatic Abscess -

SGOT 49.26/948u/l SGPT 51/5-49u/l

RBC 3.27/4.56.0

Hypothalamus Paracetamo l T 37.9 C

Penrose drainage

Pus from liver might spread to lungs

Pleural thickening vs minimal pleural effusion,right Postcholecystecto my

Shortness of breath Ciprofloxaci n

Direct Bilirubin 108.9/3.4-13.8 umol/l Indirect Bilirubin 113.1/0-10 umol/l Total Bilirubin 222/8.5-23.6 umol/l Unable to conjugate and excrete bilirubin Back up to liver and reabsorbed into blood circulation Bile salt unable to secrete Itching LIVER ABSCESS Jaundice and Icteric Sclera

Histamine Release Vasodilate Rubor/Redness

Alternate hot and cold compres Page 39

- Diphenhydramin - hydroxyzine

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Assessment Subjective Data: Mainit ang pakiramdam ko as verbalized by the patient Objective Data: Core Temperature of 37.9 degree Celsius Resiratory Rate of 24 cpm Flushed and warm skin

Diagnosis Hyperthermia related to infection as evidenced by core temperature of 37.9 degree celcius, RR of 24 cm and flushed and warm skin.

Actual Nursing Care Plan Planning Implementation Intervention Rationale SHORT TERM Independent: GOAL: Promote To restore Within 1 hr of surface cooling normal body nursing by means of cool temperature by intervention tepid sponge means of heat patient will bath especially in loss by decrease his groin and axilla evaporation and body conduction temperature to 37.2 degree Maintain bed Celsius rest To reduce metabolic demands Increase fluid intake Decrease in fluid intake may cause dehydration To enhance body temperature To prevent further complication -Central

Evaluation After 1 hr of nursing intervention patients body temperature became 37.4 degree Celsius

Provide cool clothing Monitor vital signs:

-BP

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-RR

hypertension or peripheral/postur al hypotension can occur. -Hyperventilation may initially be present, but ventilator effort may eventually be impaired by seizures and hyper metabolic state. -To prevent further increase in temperature that may lead to seizure and shock -Dysrhythmias are common due to hyperthermia on blood and cardiac tissues

-Temp

-Heart Rate

Dependent: Administer antipyretics as indicated Administer medication such LIVER ABSCESS

To reduce increased body Page 42

as antibiotics Collaborative: Provide health teaching regarding the importance of adequate fluid intake

temperature To treat underlying cause for infection

To prevent dehydration

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Assessment Subjective Data: Nahihirapan ako kumilos kasi masakit ang tyan ko as verbalized by the patient Objective Data: Abnormal Heart Rate Dysrythmias Sudden change in BP

Diagnosis Risk for Activity Intolerance related to pain

Risk Nursing Care Plan Planning Implementation Intervention Rationale SHORT TERM Independent: GOAL: Evaluate To provide Within 4 hrs or current degree of comparative nursing deficit in light of baseline intervention usual status patient will identify and Adjust activities To prevent over participate (reduce intensity exertion alternative ways level or to maintain discontinue desired activity activities that level cause undesired physiologic changes) Provide rest periods between activities Promote comfort measures and provide for relief of pain Provide positive atmosphere while To reduce fatigue

Evaluation After 4 hrs of nursing intervention patient identified and participated alternative ways to maintain desired activity level

To enhance ability to participate in activities Help to minimize Page 44

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acknowledging difficulty of situation for the client Dependent: Assist with activities Collaborative: Refer appropriate sources for assistance or equipment as needed

frustration and rechannel energy

To protect client from injury

To sustain activity level

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Assessment Nihihiya nga ako sa asawa ko dahil di na ako nakakapagbigay ng pero tapos nagging pabigat pa ako dahil kailangan nya pa akong bantayan dito sa ospital, pero ganun talaga kailangan ko muna tumigil dito, babawi nalang ako sa kanya pag lumakas na ako, ako naman ang magtatrabaho as verbalized by the patient Objective Data: Respect for family members LIVER ABSCESS

Diagnosis Readiness for enhanced family processes

Wellness Nursing Care Plan Planning Implementation Intervention Rationale SHORT TERM Establish Stress Facilitates GOAL: importance of ongoing continuous, open expression of Within 2 hrs of dialog between open, honest nursing family members feelings and intervention opinion and patient will effective problem demonstrate solving individual involvement in Assist family to Promotes problem solving identify and recognition of to improve family encourage use of previous success communications previously and confidence in successful coping own abilities to behaviors learn and improve family interactions Encourage participation in Help individuals learning roleto gain insight reversal activities and understanding of other persons feelings and point Provide of view

Evaluation After 2 hrs or nursing intervention patient demonstrated individual involvement in problem solving to improve family communications

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are evident Family roles are flexible and appropriate for developmental stages

educational materials and information

Enhances learning to assist in developing relationship among family members

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EVALUATION The student nurses are proud to pronounce that we were able to meet the objectives we set which are the following: 1. For the participants/critics, for us presenters & significant others to have a better understanding on the disease process. 2. To have the pathophysiology and to trace the occurrence of Liver abscess. 3. To utilize properly the nursing process (assessment, diagnosis, planning, intervention, evaluation) as the framework for the care of the patient. 4. To learn various medications, its condition, adverse effects & accompanying nursing responsibilities. 5. To put into action what we have learned in the school (such as nursing process) and apply our knowledge in providing quality and individualized nursing care. 6. To enhance groups attitude, like discipline, cooperation, leadership abilities and teamwork in making and presenting a case presentation.

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