CASE

STUDY
SUBMITTED BY:
ARIANE MAE C.
RAMISCAL
BSN III-2
SUBMITTED TO:

MR. JUANITO C.
LEABRES
PATIENTS PROFILE
NAME: Vergel Perez
AGE: 40 years old
BIRTHDAY: 09/13/1976
ADDRESS: Lawang Lupa San Antonio
OCCUPATION: Farmer
RELIGION: Iglesia ni Cristo
HEIGHT: 53
WEIGHT: 62kg
MOTHER: Anita Santiago Perez
FATHER: Ruperto Perez
WIFE: Christy Pallarca Perez

CHIEF COMPLAINT
Headache

DIAGNOSIS
Multiple Physical Injury Secondary to
Vehicular Crush
Minimum Traumatic Brain Injury LW Right
EAR.

MEDICATION
Ranitidine 50mg every 8hours
Cefuroxime 750mg every 8 hours

PHYSICAL EXAMINATION
With wound at LOWER RIGHT EAR.
GCS-12
LAB EXAM:
CBC-APC
ALLERGIES: None as Self Claimed

DRUG STUDY

DRUG
The route stated on the patients prescription
chart should match the type of enteral tube and
the placement of the tip of the enteral tube in the
gastrointestinal tract, for example, nasogastric
(NG), percutaneous endoscopic gastrostomy
(PEG) or nasojejunal (NJ).
Never assume that a drug can be given via a
feeding tube - always ask a pharmacist for
advice.
In order for the drug to have bioavailability (be
able to be absorbed and used), it must be
delivered to the correct part of the
gastrointestinal tract. If a drug designed for
absorption in the stomach is placed directly into

the jejunum, this may compromise its overall

effect.
For example, digoxin is primarily absorbed in the
stomach, therefore administering digoxin via a
jejunal tube may significantly reduce the rate of
absorption.
Drug doses may alter if the formulation of a drug
is changed. For example, if a prescription of a
drug is changed from a slow-release formulation
to a liquid, the drug dose and the frequency may
need to be recalculated.
Not all liquid drug preparations are suitable for
enteral tube administration. The osmolality of
some drugs may be high (causing fluid to be
drawn into the gastrointestinal tract) and some
preparations contain sorbitol. Both of these may
cause diarrhoea and hence failure of drug
absorption.

If the drugs do not appear to be working or the

patient experiences diarrhoea, the pharmacist
and dietitian should review the patients
medicines and feeding regime.
Enteral feeds may bind with some drugs and
stop their absorption. For example, it is important
to stop the enteral feed for two hours before
phenytoin is administered via an enteral feeding
tube and for two hours afterwards.
Before and after administration the tube should
be flushed with water to prevent the drug binding
to the feed and dramatically reducing serum
levels.
Adding drugs directly to a feed container can
lead to contamination. It can also destabilise the
feed or the drug and lead to chemical
interactions.

Procedure for drug

administration via an
enteral feeding tube
Before administering a drug via an enteral
feeding tube, it is important to:
- Wash hands and wear gloves;
- Resecure and refix any tape holding the enteral
feeding tube in position if loose;
- Close any ports on the enteral tube to ensure
there is an airtight seal. Check if a connector to
join the syringe to the tube is required, such as a
PEG tube connector;

- Check the position of the tube. To confirm the

gastric placement of the nasogastric tube, follow
local policy. The position of a PEG or
surgical/radiological jejunostomy can be
assessed by checking that the length of tube
outside the body remains constant and the
suture remains intact. Confirm that the patient is
not experiencing undue pain or discomfort.
- Check that the enteral feeding tube is patent by
flushing with 30-50ml of water using a 50ml oral,
enteral or catheter-tipped syringe. Do not use
syringes designed for intravenous use. Oral,
enteral and catheter-tipped syringes are not
compatible with intravenous devices and their
use reduces the risk of the drug being
accidentally administered via the intravenous
route.

- If the tube is blocked, attempt to unblock it

without using excessive force (Box 1). If
unsuccessful seek specialist advice.

Administering the
drug
- Check prescription for the drug dose, route and
site of administration according to local policy.
Draw the required dose of the liquid drug into an
appropriate syringe and place the syringe in a
clean receiver.
- Tablet-crushing must only be considered as a
last resort. Check with the pharmacist whether
tablets can be crushed, and check your trusts
preferred method of tablet-crushing. A tabletcrushing syringe (available from the pharmacy)
or pestle and mortar can be used. Crushed

tablets can be added to 30ml of water and

dissolved.
- Prepare a flush of water in a syringe and label if
necessary. Place it in the receiver with the
medicines to be administered. Tubes should be
flushed before, during (if the suspension is thick,
for example lactulose), and after drug
administration to prevent interactions between
the drugs, tube or feed. In some cases, for
example in children or in patients with renal and
cardiac disease, these volumes may need to be
revised to meet the patients prescribed fluid
restriction.
- Check the patients identity. Attach the syringe
to a port on the enteral feeding tube. Ensure
there is an airtight connection between the
syringe and enteral tube, and administer the
flush and drugs.

- Flush immediately with an appropriate amount

of water and leave the connector clean and dry.

Conclusion
Variations in practice do exist and the British
Association for Parenteral and Enteral Nutrition
(BAPEN) guidelines attempt to provide a safe
method of drug prescription and delivery that will
maximise effectiveness of the drug therapy.
Altering drugs - for example by crushing - for
administration in enteral feeding tubes may not
be covered by the drug manufacturers licence. It
is important to remember that the person
administering the drug takes responsibility for
complications that arise from his or her actions.

DIAGNOSTIC PROCEDURE
Gastrostomy is a surgical procedure for inserting a tube through the abdomen wall and into the
stomach. The tube, called a "g-tube," is used for feeding or drainage.
Gastrostomy is performed because a patient temporarily or permanently needs to be fed directly
through a tube in the stomach. Reasons for feeding by gastrostomy include birth defects of themouth,
esophagus, or stomach, and neuromuscular conditions that cause people to eat very slowly due to the
shape of their mouths or a weakness affecting their chewing and swallowing muscles.
Gastrostomy is also performed to provide drainage for the stomach when it is necessary to bypass a
longstanding obstruction of the stomach outlet into the small intestine. Obstructions may becaused by
peptic ulcer scarring or a tumor.

NCP

Nursing Interventions

Rationale
Provides rest for GI tract during acute
postoperative phase until return of normal

Maintain patency of NG tube. Notify

function. Note: The physician or surgeon

physician if tube becomes dislodged.

may need to reposition the tube

endoscopically to prevent injury to the
operative area.
Will be bloody for first 12 hr, and then should

Note character and amount of gastric

drainage.

clear and turn greenish. Continued or

recurrent bleeding suggests complications.
Decline in output may reflect return of GI
function.

Caution patient to limit the intake of ice

chips.

Provide oral hygiene on a regular, frequent

basis, including petroleum jelly for lips.

Auscultate for resumption of bowel sounds

and note passage of flatus.

Excessive intake of ice produces nausea

and can wash out electrolytes via the NG
tube.
Prevents discomfort of dry mouth and
cracked lips caused by fluid restriction and
the NG tube.
Peristalsis can be expected to return about
the third postoperative day, signaling
readiness to resume oral intake.

Monitor tolerance to fluid and food intake,

Complications of paralytic ileus, obstruction,

noting abdominal distension, reports of

delayed gastric emptying, and gastric

increased pain, cramping, nausea and

dilation may occur, possibly requiring

vomiting.

reinsertion ofNG tube.

Avoid milk and high-carbohydrate foods in

the diet.

May trigger dumping syndrome.

Note admission weight and compare with

Provides information about adequacy of

subsequent readings.

dietary intake and determination of

Nursing Interventions

Rationale
nutritional needs.

Administer IV fluids, TPN, and lipids as

Meets fluid and nutritional needs until oral

indicated.

intake can be resumed.

Monitor laboratory studies (Hb and Hct,

electrolytes, and total protein, prealbumin).

Indicators of fluid and nutritional needs and

effectiveness of therapy, and detects
developing complications.
Usually NG tube is clamped for specified

Progress diet as tolerated, advancing from

periods of time when peristalsis returns to

clear liquid to bland diet with several small

determine tolerance. After NG tube is

feedings.

removed, intake is advanced gradually to

prevent gastric irritation and distension.

Administer medications as indicated:

Anticholinergics: atropine, propantheline

Controls dumping syndrome, enhancing

bromide (Pro-Banth -ne);

digestion and absorption of nutrients.

Removal of the stomach prevents absorption

Fat-soluble vitamin supplements, including

vitamin B12, calcium;

of vitamin B12 (owing to loss of intrinsic

factor) and can lead to pernicious anemia. In
addition, rapid emptying of the stomach
reduces absorption of calcium.

Iron preparations;

Protein supplements;
Pancreatic enzymes, bile salts;
Medium-chain triglycerides (MCT).

Corrects and prevents iron

deficiency anemia.
Additional protein may be helpful for tissue
repair and healing.
Enhances digestive process.
Promotes absorption of fats and fat soluble
vitamins to prevent malabsorption problems.

2. Deficient Knowledge

Nursing Diagnosis

Knowledge Deficit

May be related to

Lack of exposure/recall

Information misinterpretation

Unfamiliarity with information resources

Possibly evidenced by

Questions, statement of misconception

Inaccurate follow-through of instruction

Development of preventable complications

Desired Outcomes

Verbalize understanding of procedure, disease process/prognosis.

Verbalize understanding of functional changes.

Identify necessary interventions/behaviors to maintain appropriate weight.

Correctly perform necessary procedures, explaining reasons for actions.

Nursing Interventions

Rationale

Review surgical procedure and long-term

Provides knowledge base from which

expectations.

informed choices can be made. Recovery

following gastric surgery is often slower than
may be anticipated with similar types
ofsurgery. Improved strength and partial
normalization of dietary pattern may not be
evident for at least 3 mo, and full return to
usual intake (three normal meals per day)
may take up to 12 mo. This prolonged
convalescence may be difficult for the

Nursing Interventions

Rationale
patient and SO to deal with, especially if he
or she has not been prepared.

Discuss and identify stress situations and

how to avoid them. Investigate job-related
issues.

Can alter gastric motility, interfering with

optimal digestion. Note: Patient may require
vocational counseling if change in
employment is indicated.

Review dietary needs and regimen (low-

May prevent deficiencies, enhance healing,

carbohydrate, low-fat, high-protein) and

and promote cooperation with therapy. Note:

importance of maintaining vitamin

Low-fat diet may be required to reduce risk

supplementation.

of alkaline reflux gastritis.

Discuss the importance of eating small,

frequent meals slowly and in a relaxed

These measures can be helpful in avoiding

atmosphere; resting after meals; avoiding

gastric distension, irritation or stress on

extremely hot or cold food; restricting high-

surgical repair, dumping syndrome, and

fiber foods, caffeine, milk products and

reactive hypoglycemia. Note: Ice-cold fluids

alcohol, excess sugars and salt; and taking

and foods can cause gastric spasms.

fluids between meals, rather than with food.

Remaining gastric tissue may have reduced
Instruct in avoiding certain fibrous foods, and

ability to digest such foods as citrus skin or

discuss the necessity of chewing food well.

seeds, which can collect, forming a mass

(phytobezoar formation) that is not excreted.

Recommend foods containing pectin (citrus

fruits, bananas, apples, yellow vegetables,
and beans).

Increased intake of these foods may reduce

incidence of dumping syndrome.
Limiting or avoiding these foods reduces risk

Identify foods that can cause gastric irritation

and increase gastric acid (chocolate, spicy
foods, whole grains, raw vegetables).

of gastric bleeding and ulceration in some

individuals. Note: Ingesting fresh fruits to
reduce risk of dumping syndrome should be
tempered with adverse effect of gastric
irritation.

Nursing Interventions

Rationale

Identify symptoms that may indicate

dumping syndrome, (weakness, profuse

Can cause severe discomfort or even shock,

perspiration, epigastric fullness, nausea and

and reduces absorption of nutrients. Usually

vomiting, abdominal cramping, faintness,

self-limiting (13 wk after surgery) but can

flushing, explosive diarrhea, and palpitations

become chronic.

occurring within 15 min to 1 hr after eating).

Discuss signs of hypoglycemia and
corrective interventions, (ingesting cheese
and crackers, orange or grape juice).
Suggest patient weight self on a regular
basis.

Awareness helps patients take actions to

prevent progression of symptoms.
Change in dietary pattern, early satiety, and
efforts to avoid dumping syndrome may limit
intake, causing weight loss.
Understanding rationale and therapeutic
needs can reduce risk of complications

Review medication purpose, dosage, and

( anticholinergics or pectin powder may be

schedule and possible side effects.

given to reduce incidence of dumping

syndrome; antacids and histamine
antagonists reduce gastric irritation).

Caution patient to read labels and avoid

products containing ASA, ibuprofen.

Can cause gastric irritation and bleeding.

Smoking stimulates gastric acid production

Discuss reasons and importance of

cessation of smoking.

and may cause vaso constriction,

compromising mucous membranes and
increasing risk of gastric irritation and
ulceration.

Identify signs and symptoms requiring

Prompt recognition and intervention may

medical evaluation such as persistent

prevent serious consequences or potential

nausea and vomiting or abdominal fullness;

complications such as pancreatitis,

weight loss; diarrhea; foul-smelling fatty or

peritonitis, and afferent loop syndrome.

tarry stools; bloody or coffee-ground vomitus

Nursing Interventions

Rationale

or presence of bile, fever. Instruct patient to

report changes in pain characteristics.
Stress importance of regular checkup with
healthcare provider.

Necessary to detect developing

complications (anemia, problems with
nutrition, and recurrence of disease).

Nursing Diagnosis for Gastrostomy

1.
Imbalanced nutrition, less than bodyrequirements, related to enteral feeding problems
2.
Risk for infection related to presence of wound and tube
3.
Risk for impaired skin integrity at tube site
4.
Ineffective coping related to inability to eat normally
5.
Disturbed body image related to presence of tube
6.
Risk for ineffective therapeutic regimen management related to knowledge deficit about home
care and the feeding procedur.

HISTORY
Jejunostomy is the surgical creation of an opening (fistula) through the skin at the front of the
abdomen and the wall of thejejunum (part of the small intestine). It can be performed
either endoscopically, or with formal surgery.[1]
A jejunostomy may be formed following bowel resection in cases where there is a need for
bypassing the distal small bowel and/or colon due to a bowel leak or perforation. Depending on the
length of jejunum resected or bypassed the patient may have resultant short bowel syndrome and
require parenteral nutrition.[2]
A jejunostomy is different from a jejunal feeding tube which is an alternative to a gastrostomy feeding
tube commonly used when gastric enteral feeding is contraindicated or carries significant risks. The
advantage over a gastrostomy is its low risk of aspirationdue to its distal placement. Disadvantages
include small bowel obstruction, ischemia, and requirement for continuous feeding.