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Foundation University

COLLEGE OF NURSING
Dumaguete City

LIFE PURPOSE:
The life purpose of Foundation University is to educate and develop individual to become productive, creative, useful and responsible citizens of society.

VISION:
Foundation University envisions itself as a dynamic, progressive environment that cultivates effective learning, generates creative ideas, responds to societal needs
and offers equal opportunity for all.

MISSION:
To enhance and promote a climate of excellence relevant to the challenges of the times, where individuals are committed to the pursuit of new knowledge and life
long learning in service of society.

CORE VALUES

 Excellence
 Commitment
 Integrity
 Service
September 19, 2017

Mr. Kennith C. Misamis BSN-RN


Clinical Instructor – Surgery Ward
Foundation University College of Nursing
Dumaguete City

Dear Mr. Misamis

Good Day!

In partial fulfillment of my requirement in NCM 103, I Ailyne A. Cleofe, Level – III Nursing Student of Foundation University, would like to apply a case analysis
for my client Miss.J.L 22 year old, Acute Pancreatitis patient and currently residing in Sta. Catalina Negros Oriental. She was admitted in the Surgery Ward PTA she
was punched by her live-in partner, hitting her periumbilical area. The patient got dizzy and had three episodes of vomiting of which contained food particles. No
associated loss of consciousness reported. The patient had abdominal pain associated with abdominal rigidity. The patient was diagnosed with Acute Pancreatitis
secondary to Blunt Abdominal Injury.
This study will enable me to develop my critical thinking skills and comprehension not only on this case but in future cases as well

I am looking forward to your positive response.

Thank you very much!

Respectfully yours,

Ailyne A. Cleofe
BSN-III
Objectives of the Study:
Topic Description: This topic implies to the case about Acute Pancreatitis

General Objectives:

At the end of the 1 hour lecture-discussion the learners shall gain adequate knowledge, develop competent skills, and manifest desirable attitudes and positive values
in the care of patient with Acute Pancreatitis.

During the case presentation, the learners will:

 gain knowledge of the underlying cause of Acute Pancreatitis;


 trace and fully understand the study related to Acute Pancreatitis;
 relate the signs and symptoms manifest by the client;
 identify all nursing interventions with rationales done to the patient;
 express understanding and appreciation of my case presentation;
 familiarize themselves with the demographic profile of the patient;
 identify the patient’s development milestone of middle adulthood;
 discuss the nursing history of the patient including the chief complaint, admitting diagnosis, history of present illness, past health history, family history;
 discuss the findings on physical assessment with the system involved;
 describe the anatomy and physiology of the significant body system related to the condition;
 trace the pathophysiology of the condition and relate to actual experience of the client;
 describe the medical management used during the care of the client with Acute Pancreatitis;
 discuss the nursing theory that is applicable to the care of the patient;
 discuss the nursing care plan of the patient.
INTRODUCTION

Pancreatitis is an uncommon disease characterized by inflammation of the pancreas. Acute pancreatitis affects about 50,000–80,000 Americans each year. It is a
condition that arises suddenly and may be quite severe, although patients usually have a complete recovery from an acute attack.

The pancreas is located deep in the retroperitoneal space of the upper part of the abdomen (Figure 1). It is almost completely covered by the stomach and duodenum.
This elongated gland (12–20 cm long in the adult) has a lobe-like structure. Variation in shape and exact body location is common. In most people, the larger part of
the gland’s head is located to the right of the spine or directly over the spinal column and extends to the spleen. The gland has both exocrine and endocrine functions.
In its exocrine capacity, the acinar cells produce digestive juices, which are secreted into the intestine and are essential in the breakdown and metabolism of proteins,
fats, and carbohydrates. In its endocrine function capacity, the pancreas also produces insulin and glucagon, which are secreted into the blood to regulate glucose
levels.
Acute pancreatitis refers to an acute inflammatory process of the pancreas, usually accompanied by abdominal pain and elevations of serum pancreatic enzymes.
This syndrome is usually a discrete episode, which may cause varying degrees of injury to the pancreas, and adjacent and distant organs. The incidence of acute
pancreatitis has wide variability within populations, with about 1–5 cases per 10,000 population per year. Eighty percent of the cases of acute pancreatitis in United
States are related to alcohol use or biliary stones.

Pancreatitis may be classified as mild, moderate, or severe based on physiological findings, laboratory values, and radiological imaging. Mild disease is not associated
with complications or organ dysfunction and recovery is uneventful. In contrast, severe pancreatitis is characterized by pancreatic dysfunction, local and systemic
complications, and a complicated recovery.

In addition, pancreatitis may be further classified into acute interstitial and acute hemorrhagic disease (Figure 2). In the first type, the gland architecture is preserved
but is edematous. Inflammatory cells and interstitial edema are prominent within the parenchyma. Hemorrhagic disease is characterized by marked necrosis,
hemorrhage of the tissue, and fat necrosis. There is marked pancreatic necrosis along with vascular inflammation and thrombosis
ACKNOWLEDGEMENT
First and foremost I would like to express my special thanks to Almighty God who never fail to guide, protect and watched over me all the time when we were in
Surgery Ward of Negros Oriental Provincial Hospital (NOPH) to fulfill our duty.

Secondly, To the College of Nursing of Foundation University, Faculty and Staff who gave us all the support. We are so grateful for having you all in our side during
the completion of this case study.

Third, To my beloved guardian who helped me a lot and give the full support, especially to all my financial needs. I am forever thankful to have you.

To my cherish patient, who made herself available for us to be able to carry our nursing skills and for giving us the time and patience during the time consuming
interview, thank you for the trust.

To my Clinical Instructor, Mr. Kennith C. Misamis who gave me the golden opportunity to develop my skills and allow me to experience interesting task and
procedures, for helping me and guiding me all the time in the Surgery Ward, Thank you for the trust, may God bless you and give you more courage to help me along
the way.

To our fellow classmates who helped us and always there to be our company during our duty, thank you guys.
DEMOGRAPHIC PROFILE

Name: J.L. Room & Bed #: ABS

Address: Sta. Catalina, Negros Oriental

Sex: Female Date of Birth: May 10, 1995

Age: 22

Marital Status: Single Educational Attainment: High School Graduate

Nationality: Filipino

Occupation: Cashier

Religion: Roman Catholic

Chief Complaint: “Gikan ko gi operahan tungod sa acute pancreatitis, gasakit ako tiyan, maong naglisod ko ginhawa” as verbalized by the patient

Medical Diagnosis: Acute Pancreatitis

History of Present Illness: 7 hours PTA on July 31 2017, pt was punched by her live-in partner, hitting her periumbilical area. Pt got dizzy and had three episodes of
vomiting of which contained food particles. No associated loss of consciousness reported.

On August 27, 2017 the patient re-admitted again due to severe abdominal pain and shortness of breath.

General Impression:
As the assessement revealed for the general appearance the findings was she has a poor body coordination and it is abnormal that affects body movement and posture.
Her body becomes either very floppy or very stiff because of her condition and because of just laying on bed most of the time. The body and breath odors I found out
that she is having a foul mouth odor that can result from poor oral hygiene, or suffer from different tooth problem. About the psychological presence, she was clean
and neat and dress properly. When I talked to her she’s so cooperative that she’s the one who wants to talked everything about her life
GROWTH AND DEVELOPMENT
Erik Erikson Developmental Stage

Each stage in Erikson's theory builds on the preceding stages and paves the way for following periods of development. In each stage, Erikson believed people
experience a conflict that serves as a turning point in development. In Erikson's view, these conflicts are centered on either developing a psychological quality or failing to
develop that quality. During these times, the potential for personal growth is high but so is the potential for failure.

If people successfully deal with the conflict, they emerge from the stage with psychological strengths that will serve them well for the rest of their lives.

Intimacy vs. Isolation


Occurring in young adulthood (ages 18 to 40 yrs), we begin to share ourselves more intimately with others. We explore relationships leading toward longer-
term commitments with someone other than a family member.
Successful completion of this stage can result in happy relationships and a sense of commitment, safety, and care within a relationship. Avoiding intimacy, fearing
commitment and relationships can lead to isolation, loneliness, and sometimes depression. Success in this stage will lead to the virtue of love.
Implication
In my client, she is 22 year old, she is just about to start her journey to adulthood but unfortunately she is not happy in her relationship. She already have two
kids at the age of 20. In her young age she experienced being bitten by her live-in partner, at the age of 22 she undergone Exploratory Laparotomy because of unhappy
life that lead to traumatic incident . At her age she is still exploring the essence of life and she did not reach yet the Intimacy or Isolation.
Freud’s Psychosexual Theory
According to Freud’s psychoanalytic theory, personality develops through a series of stages, each characterized by a certain internal psychological conflict.

According to Freud, our personality develops from the interactions among what he proposed as the three fundamental structures of the human mind: the id,
ego, and superego. Conflicts among these three structures, and our efforts to find balance among what each of them “desires,” determines how we behave and approach
the world. What balance we strike in any given situation determines how we will resolve the conflict between two overarching behavioral tendencies: our biological
aggressive and pleasure-seeking drives vs. our socialized internal control over those drives.

The Genital Stage


Age Range: Puberty to Death
Erogenous Zone: Maturing Sexual Interests

During the final stage of psychosexual development, the individual develops a strong sexual interest in the opposite sex. This stage begins during puberty but
last throughout the rest of a person's life.

Where in earlier stages the focus was solely on individual needs, interest in the welfare of others grows during this stage. If the other stages have been completed
successfully, the individual should now be well-balanced, warm and caring. The goal of this stage is to establish a balance between the various life areas.

Implication

Miss J.L. at the age of 22 she already reach the stage of developing relationship with opposite sex. She already have two kids, 1 year old and two year old
boys. During my interview with her, she was unhappy with her relationship to her live-in partner, as she verbalized, she was hospitalized because of jealousy between
her and an allegation that her live-in partner has other woman, she also verbalized that she was always stress with her job which is there is no time for her to relax
because there is no day off on her previous job. In my implication, Miss J.L. did not met yet the successful stage of this theory.
GENOGRAM – LANGUITA FAMILY

Male :

Female:

Deceased:
Anatomy and Physiology
Pancreas
The pancreas lies behind the peritoneum of the posterior abdominal wall and is oblique in its orientation. The head of the pancreas is on the right side and lies
within the “C” curve of the duodenum at the second vertebral level (L2). The tip of the pancreas extends across the abdominal cavity almost to the spleen. Collecting
ducts empty digestive juices into the pancreatic duct, which runs from the head to the tail of the organ. The pancreatic duct empties into the duodenum at the duodenal
papilla, alongside the common bile duct.

The Duct of Wirsung is the main pancreatic duct extending from the tail of the organ to the major duodenal papilla or Ampulla of Vater . The widest part of
the duct is in the head of the pancreas (4 mm), tapering to 2 mm at the tail in adults. The duct of Wirsung is close, and almost parallel, to the distal common bile duct
before combining to form a common duct channel prior to approaching the duodenum. In approximately 70% of people, an accessory pancreatic duct of Santorini
(dorsal pancreatic duct) is present. This duct may communicate with the main pancreatic duct. The degree of communication of the dorsal and ventral duct varies from
patient to patient.
Smooth circular muscle surrounding the end of the common bile duct (biliary sphincter)
and main pancreatic duct (pancreatic sphincter) fuses at the level of the ampulla of Vater
and is called the sphincter of Oddi.

This musculature is embryologically, anatomically, and physiologically different from


the surrounding smooth musculature of the duodenum. The normal appearance through
the endoscope includes the major and minor papilla. The major papilla extends 1 cm into
the duodenum with an orifice diameter of 1 mm. The minor papilla is 20–30 mm proximal
and medial. Its orifice is tiny and may be difficult to identify (Figure 4B). Dysfunction of
this muscle may result in unexplained abdominal pain or pancreatitis.

The sphincter of Oddi is a dynamic structure that relaxes and contracts to change the dimensions of the ampulla of Vater.
The pancreas may be divided into five major regions—the head, neck, body, tail and uncinate process. The distal end of the common bile duct can be found behind
the upper border of the head of the pancreas. This duct courses the posterior aspect of the pancreatic head before passing through the head to reach the ampulla of
Vater (major papilla). The uncinate process is the segment of pancreatic tissue that extends from the posterior of the head. The neck of the pancreas, a part of the gland
3–4 cm wide, joins the head and body. The pancreatic body lies against the aorta and posterior parietes, and anteriorly contacts the antrum of the stomach.
ANATOMY AND PHYSIOLOGY

Integumentary System

The skin and its derivatives (sweat and oil glands, hair and nails) serve a number

of functions, mostly protective; together, these organs are called the integumentary system.

Structure of the Skin

Composed of two kinds of tissue: the outer epidermis and the underlying dermis.

Epidermis

The outer epidermis composed of stratified squamous epithelium that is capable of keratinizing

or becoming hard and tough.

Composition the epidermis is composed of up to five layers or strata; from the inside out these are the: stratum basale, spinosum, granulosum, lucidum, and corneum.

Epithelial tissue like all other epithelial tissues, the epidermis is avascular; that is, it has no blood supply of its own.

Keratinocytes most cells of the epidermis are keratinocytes (keratin cells), which produce keratin, the fibrous protein that makes the epidermis a tough protective
layer.

Stratum basale the deepest layer of the epidermis, the stratum basale, lies closest to the dermis and is connected to it along a wavy a borderline that resembles
corrugated cardboard; this basal layer contains epidermal cells that receive the most adequate nourishment via diffusion of nutrients from the dermis.
Stratum spinosum as the epidermal layers move away from the dermis and become part of the more superficial layers, the stratum spinosum.

Stratum granulosum upon reaching the stratum granulosum, the layers become flatter and increasingly full of keratin.

Stratum lucidum. Finally, they die, forming the clear stratum lucidum; this latter epidermal layer is not present in all skin regions, it occurs only where the skin is
hairless and extra thick, that is, on the palms of the hands and soles of the feet.

Stratum corneum the outermost layer, the stratum corneum, is 20 to 30 cells layers thick but it accounts for about three-quarters of epidermal thickness; it rubs and
flakes off slowly and steadily as the dandruff familiar to everyone; then, this layer is replaced by cells produced by the division of the deeper stratum basale cells.

Cornified cells the shinglelike dead cell remnants, completely filled with keratin, are referred to as cornified or horny cells.

Keratin is an exceptionally tough protein; its abundance in the stratum corneum allows that layer to provide a durable “overcoat” for the body, which protects deeper
cells from the hostile external environment.

Melanin a pigment that ranges in color from yellow to brown to black, is produced by special spider-shaped cells called melanocytes, found chiefly in the stratum
basale.

Melanosomes as the melanocytes produce melanin, it accumulates within them in membrane-bound granules called melanosomes; these granules then move to the
ends of the spidery arms of the melanocytes, where they are taken up by nearby keratinocytes.

Dermis

The underlying dermis is mostly made up of dense connective tissue.

Major regions the dense (fibrous) connective tissue making up the dermis consists of two major regions- the papillary and reticular regions.
Papillary layer is the upper dermal region; it is uneven and has peglike projections from its superior surface called dermal papillae, which indent the epidermis above
and contain capillary loops which furnish nutrients to the epidermis; it also has papillary patterns that form looped and whorled ridges on the epidermal surface that
increase friction and enhance the gripping ability of the fingers and feet.

Reticular layer is the deepest skin layer; it contains blood vessels, sweat and oil glands, and deep pressure receptors called Pacinian corpuscles.

Collagen fibers are responsible for the toughness of the dermis; they also attract and bind water and thus help to keep the skin hydrated.

Elastic fibers give the skin its elasticity when we are young, and as we age, the number of collagen and elastic fibers decreases and the subcutaneous tissue loses fat.

Blood vessels the dermis is abundantly supplied with blood vessels that play a role in maintaining body temperature homeostasis; when body temperature is high, the
capillaries of the dermis becomes engorged, or swollen, with heated blood, and the skin becomes reddened and warm; if the environment is cool, blood bypasses the
dermis capillaries temporarily, allowing internal body temperature to stay high.

Nerve supply the dermis also has a rich nerve supply; many of the nerve endings have specialized receptor end-organs that send messages to the central nervous
system for interpretation when they are stimulated by environmental factors.
Abdomen

The osteology of abdomen deals with the bones of the abdomen and pelvis. The bones of the abdomen and pelvis are as follows:

1. Lower ribs and costal cartilages.

2. Lumbar vertebrae.

3. Sacrum

4. Coccyx

5. Hip or innominate bone.


The ribs and costal cartilages are described in detail in Anatomy of Upper Limb and Thorax. The costal cartilages of 7th, 8th, 9th, and 10th ribs articulate wit
h each other to form the costal margin. The 11th and 12th ribs are shorter and do not artic- ulate either with the transverse processes of 11th and 12th thoracic
vertebrae or with the adjacent costal cartilages. As a result they can move independently of the other ribs hence are termed floating ribs.

The lumbar vertebrae consist of same elements as the thoracic vertebrae but are more massive in keeping with the greater load, which they have to transmit. There are
five lumbar vertebrae out of which first four (L1 to L4) are typical and fifth (L5) is atypica.
Along with the organs of the digestive system, the abdomen also contains the spleen; the urinary tract including the bladder, kidneys, and ureters; the uterus
and ovaries; the aorta; and the iliac, renal, and femoral arteries. The uterus and ovaries are covered in Chapter 18,Assessing the Female Genitourinary System.The
other abdominal organs are shown in Figure 17.2. The abdominal cavity has a serous membrane called the peritoneum, which covers the organs and holds them in
place.The peritoneum contains a parietal layer that lines the walls of the abdomen and the visceral pleura, which coats the outer surface of the organs. A small amount
of fluid between these membranes allows them to move smoothly within the cavity.
Respiratory System

The respiratory system is situated in the thorax, and is responsible for gaseous exchange between the circulatory system and the outside world. Air is taken in
via the upper airways (the nasal cavity, pharynx and larynx) through the lower airways (trachea, primary bronchi and bronchial tree) and into the small bronchioles
and alveoli within the lung tissue.

The lungs are divided into lobes; The left lung is composed of the upper lobe, the lower lobe and the
lingula (a small remnant next to the apex of the heart), the right lung is composed of the upper, the middle and
the lower lobes.

Mechanics of Breathing

To take a breath in, the external intercostal muscles contract, moving the ribcage up and out. The
diaphragm moves down at the same time, creating negative pressure within the thorax. The lungs are held to the
thoracic wall by the pleural membranes, and so expand outwards as well. This creates negative pressure within
the lungs, and so air rushes in through the upper and lower airways. Expiration is mainly due to the natural
elasticity of the lungs, which tend to collapse if they are not held against the thoracic wall. This is the mechanism
behind lung collapse if there is air in the pleural space (pneumothorax).
Physiology of Gas Exchange

Each branch of the bronchial tree eventually sub-divides to form very narrow terminal bronchioles, which terminate in the alveoli. There are many millions of
alveloi in each lung, and these are the areas responsible for gaseous exchange, presenting a massive surface area for exchange to occur over. Each alveolus is very
closely associated with a network of capillaries containing deoxygenated blood from the pulmonary artery. The capillary and alveolar walls are very thin, allowing
rapid exchange of gases by passive diffusion along concentration gradients. CO2 moves into the alveolus as the concentration is much lower in the alveolus than in
the blood, and O2 moves out of the alveolus as the continuous flow of blood through the capillaries prevents saturation of the blood with O2 and allows maximal
transfer across the membrane.
Acute Pancreatitis: Causes

Gallstones Gallstones are the most common cause of pancreatitis in the United States and other Western countries. Biliary tract disease accounts for 35–50%
of all cases. Despite aggressive and intensive early management, the mortality rate is approximately 10%. Although the exact mechanism of acute pancreatitis due
to gallstones is not completely understood, most investigators believe that obstruction of the major papilla by the stone causes reflux of bile into the pancreatic duct
(Figure 7). The presence of bile in the pancreatic duct appears to initiate a complex cascade effect that results in acute pancreatitis.
Alcohol Alcohol is the second leading cause of acute pancreatitis in Western countries. In many patients, however, chronic pancreatitis is already established. Alcohol
is believed to cause acute pancreatitis by several mechanisms. These include abnormal sphincter of Oddi motility, direct toxic and metabolic effects, and small duct
obstruction by protein plug formation (Figure 8).

Drugs are a well-recognized cause of pancreatitis. These drugs may be divided into those that have a definite association, and those with probable association with
the development of acute pancreatitis.

Pancreas Divisum The most common congenital anomaly of the pancreas, pancreas divisum, occurs in approximately 10% of the population, and results from
incomplete or absent fusion of the dorsal and ventralducts during embryological development. In pancreas divisum, the ventral Duct of Wirsung empties into the
duodenum through the major papilla but draining only a small portion of the pancreas (ventral portion). Other regions of the pancreas, including the tail, body, neck
and the remainder of the head, drain secretions into the duodenum through the minor papilla via the dorsal duct of Santorini .

Recent clinical trials have supported the concept that obstruction of the minor papilla may cause acute pancreatitis or chronic pancreatitis in a subgroup of patients
with pancreas divisum. Endoscopic or surgical therapy directed to the minor papilla has been effective in treating these patients. Figure 9 illustrates the appearance of
pancreas divisum on endoscopic retrograde cholangiopancreatography (ERCP) in which most of the pancreas drains through the dorsal duct (hence the term dominant
dorsal duct syndrome.
NURSING THEORY

By: Virginia Henderson


14 Basc Needs
First Lady of Nursing
First Truly International Nurse

Henderson asserted that nurses function indigently from the physician, but they must promote the treatment plan prescribed by the physician . Although part of the
health care team, the nurse must act independently but in coordination with the therapeutic plan developed by the team. Another special role of the nurse is to help
both sick and well individual. Care must include people from all walks of life, from the well and sick and from the newborn to dying. The care given by the nurse as
Henderson stressed must empower the patient to gain independence as rapidly as possible.

Henderson conceptualized the 14 Fundamental Needs of Human .These are:

 Breathing normally
 Eating and drinking adequately
 Eliminating body waste
 Moving and maintaining a desirable position
 Sleeping and resting
 Selecting suitable clothes
 Maintaining normal body temperature by adjusting clothing and modifying the environment
 Keeping the body clean and well groomed to promote integument( skin)
 Avoiding dangers in the environment and injuring others
 Communicating with others in expressing emotions needs, fears or opinion
 Worshiping according to one’s faith
 Playing or participating in various forms of recreation
 Learning , discovering or satisfying the curiosity that leads to normal development and health and using available health facilities.

Virginia Henderson is the theorist that I found to be most interested and I apply her theory to my client. I respect my patient and treat her as if I was taking care
of my family member. I assist the basic needs of my client like ensuring that she is breathing normally, moving and maintaining a desirable position during her
hospitalization, I making sure that her hygiene is good so I gave her bed bath during my duty, I was also making sure that her clothing is comfortable and suitable for
the weather.
Knowing that I make a difference on her life by truly helping her and her family, it is my greatest accomplishment to do my task to be her student nurse.
Florence Nightingale

Environmental Theory

Note that the client, the nurse, and the major environment concepts are in balance; that is; the nurse can manipulate the environment to compensate for the client’s
response to it. The goal of the nurse is to assist the patient in staying in balance. If the environment of a client is out of balance, the client expends unnecessary energy.

Nightingale stated that nursing “ought to signify the proper use of fresh air, light, warmth, cleanliness, quiet, and the proper selection and administration of diet – all
at the least expense of vital power to the patient.”

She reflected the art of nursing in her statement that, “the art of nursing, as now practised , seems to be expressly constituted to unmake what God had made disease
to be, viz., a reparative process.

The physical environment is stressed by Nightingale in her writing. Nightingale’s writings reflect a community health model in which all that surrounds human beings
is considered in relation to their state of health.

In the era that we are in today, we are faced with environmental conditions beyond what was ought to be natural and nurturing. Some of the global environmental
issues that we have now are the global warming, nuclear radiation threats, man-made environmental calamities and pollution. From these occurrences, Nightingale’s
model seemed to be very ideal. Her concept of providing fresh air to patients is in question with today’s industrialization effects.

Correlation

In the case of my client, as Florence Nightingale theory , it is truly applicable because as we all know that the environment in the hospital sometimes not favorable to
the client. During my duty as her student nurse I did my best to alleviate the discomfort of being in bed and the activity is very limited. I help her by making her bed
nice and clean, by asking her SO to change the bed sheet if it is soiled and most important thing is her hygiene. The air also is very important that is why to make sure
that she can inhale fresh air, we move her place to the bed just in front of the window. I am happy to help her and I was thankful to her because of her very cooperative
attitude.
NURSING HISTORY:
Past Health History.

7 hours PTA on July 31 2017, pt was punched by her live-in partner, hitting her periumbilical area. Pt got dizzy and had three episodes of vomiting of which contained
food particles. No associated loss of consciousness reported.

On August 27, 2017 the patient re-admitted again due to severe abdominal pain and shortness of breath..

Family Health History:

Her father is a security guard and her mother is a plain housewife. She has 2 brothers and 1 sister. They have a history of disease hypertension, arthritis, kidney
disease and asthma both on her parents. She has two brother and one sister.

Psychosocial History:

Her major stressor is the duration of her hospitalization. She felt bored in the hospital. She wants someone to talk.
For her to cope up her stressor, she talks to every person that she met. Like the other patient in the hospital.

Environmental History:

Their house are made of cement and woods. They have only four neighbors. They welcomed all persons on their house especially their relatives. They believe in
“anting-anting” for them to have a healthy life.

Spiritual History: She doesn’t usually go to church because of her previous job, but her parents regularly go to church every Sunday, her family is a Roman Catholic
and she baptized in Catholic Church.
REVIEW OF RELATED LITERATURE

Acute pancreatitis (AP) is an inflammatory disease characterized by steady, acute abdominal pain of varying severity, often radiating from the epigastrium to
the back. Its presentation ranges from a self-limiting mild disorder to a more severe and fulminant disease. Severe acute pancreatitis accounts for 30% of all deaths
related to pancreatitis. The incidence of AP is increasing progressively with a corresponding increase in the incidence of its risk factors. Alcohol abuse and gallstone
migration are the established risk factors for development of AP. In recent years, genetic factors and obesity have also been identified as risk factors responsible for
the development of AP. The pathophysiology of AP involves acute inflammation of the acinar cells. Excessive acinar cell injury leads to a condition called systemic
inflammatory response syndrome (SIRS). Protracted SIRS is responsible for most of the life-threatening complications associated with AP. Most common AP-related
complications include pulmonary, renal, cardiovascular, and central nervous system dysfunction. Thus prompt and accurate diagnosis of AP is of paramount
importance. The medical management of AP includes controlling pain, providing adequate nutritional support, and monitoring complications. Endoscopic retrograde
cholangiopancreatography and surgery have also shown to reduce the mortality and morbidity associated with AP. Drugs such as resveratrol and rosiglitazone are
being investigated as potential candidates for the treatment of AP.
CONCEPT MAP
Precipitating Factors:
 Lifestyle
Predisposing Factors: OF ACUTE PANCREATITIS  Eating food high in
 22 year old sodium
 Female  Drinking softdrinks for 1
year almost everyday
 No exercise
 Stress
 Previous medical condition
( trauma to the abdomen)

Activation of Trypsin

Activate variety of
Stimulated by reflux of bile acids
digestive enzyme
into the pancreatic ducts through
an open or distended sphincter of
Oddi
Pancreatic injury

Obstruction of pancreatic ducts

Signs and symptoms:

 Pain develops over a few


days
Pancreatic Ischemia
 Nausea and vomiting
Activated trypsin is present in the
pancreas Assay Results Units Normal Details
range

BUN2 22 mg/dl 11-36 Normal


Increase pancreatic secretions
CREA2 0.50 mg/dl 0.64-1 Low
 Obstructions of the sphincter of
Intense inflammatory response Total 6.1 g/dl 6.6-8.3 Low
the pancreatic duct
 Abdominal pain- located in the protein
epigastric or periumbilical 2.8 g/dl
region Albumin
. 3.3 g/dl 3.1-4.3 Normal
Globulin
Substantial tissue damage may 828.5 U/L 0-450 High
progress beyond the pancreas Amylase

Produce a systemic
inflammatory response
syndrome
:

Pain related to post surgical


procedure

Impaired skin integrity


S/S
related to surgery
 Nausea and vomiting
 Low-grade fever
 Leukocytosis
 Hypotension
Imbalance nutrition less  Tachycardia
than body requirements  Jaundice
 Abdominal tenderness

Infection/ abdominal and surgical


Ampicillin 750 mg IVTT q8h trauma Tramadol 5o0 mg solution IVTT q4h

Treatment for infection Relief of moderate to severe pain

Metronidazole 500 mg/100 Ml IV infusion


Ranitidine 50 mg IVTT q8h Acute pancreatitis
q6h
Relief of symptoms of heartburn and Treatment for infections
GERD
Multi-organ failure If
treated
 continuous fever, abdominal
pain, and inability to tolerate a
diet,
 development of infection in the
dead pancreatic tissue can give Treatment
rise to life-threatening infection
in the blood,
 damage to surrounding structures
in the abdomen from the Fasting , NPO order by the doctor
inflammation and leakage of
pancreatic juice such as the If not
colon, blood vessels, splenic treated
vein, and the duodenum.  Ampicillin 750 mg IVTT
q8h

Death Treatment for infection

 Metronidazole 500
mg/100 Ml IV infusion
q6h
LEGEND:
Treatment for infections
Medications:
 Tramadol 5o0 mg
S/S: solution IVTT q4h

NCP: Relief of moderate to severe


pain
Treatment:
Clear liquid diet  Ranitidine 50 mg IVTT
q8h

Relief of symptoms of
Recovery heartburn and GERD
TREATMENT MODALITIES
TREATMENT RATIONALE
July 31, 2017

 Secure consent of admission  This helps secure permission for patient treatment.
 Vital signs  For baseline data and maintain normal vital signs and detect any changes
 Please admit to ward  For patient to be admitted
 Infuse IVF @20 gtts/min  To provide patient adequate nutrition and fluid electrolytes.
 Laboratories:  To know if the diagnostic results is within the normal range.
CBC

August 2, 2017

 Diet: NPO  For STAT exploratory laparotomy, lavage, drain


 Monitor Vital signs  For proper patient care
 On call to OR  For legal purposes and to assure that the patient has been fully informed
 Secured Signed Consent on the operation to be done.
 Dr. Salindo  For Proper Staff Communication
 NPO  To avoid backflow of gastric contents.
 TSB encourage  To reduce body temperature
 D5LR 1L @20 gtts/min  A hypertonic solution, given for fluid and electrolyte replacement.

10: 35pm

 NPO  To avoid backflow of gastric contents.


 D5LR 1L @20 gtts/min  A hypertonic solution, given for fluid and electrolyte replacement.

August 5, 2017

 NPO  To avoid backflow of gastric contents.


 D5LR 1L @20 gtts/min

 Metroclopramide 1VTT 1amp


 For vomiting
August 6, 2017

 Diet: NPO  To avoid backflow of gastric content.


 D5LR 1L @20 gtts/min

 To avoid backflow of gastric content.


 . A hypertonic solution, given for fluid and electrolyte replacement.
August 27, 2017

 Seen and examined by Dr. Nervez


 IVF started/ D5LR@20gtts/min
 Lab requested
 To avoid backflow of gastric content
 NGT inserted
 . A hypertonic solution, given for fluid and electrolyte replacement
 Diet: NPO

August 28, 2017


 Diet: NPO
 On-going IVF D5LR@20 gtts/min
 To avoid backflow of gastric content
 . A hypertonic solution, given for fluid and electrolyte replacement
August 29, 2017

 Vital signs monitored


 Diet: NPO  To provide baseline data
 IVF continues D5LR@20gtts/min  To avoid backflow of gastric content
 . A hypertonic solution, given for fluid and electrolyte replacement

September 3, 2017
 A diet of clear liquids maintains vital body fluids, salts, and minerals; and
 Diet: Clear liquids
also gives some energy for patients when normal food intake must be
 Vital signs monitored
interrupted. Clear liquids are easily absorbed by the body.
MEDICAL MANAGEMENT
LABORATORY EXAMS RESULT NORMAL CORRELATION/IMPLICATIONS
VALUES

CBC
Helps fight against infection. For my patient its normal and within normal
WBC 9.1 4.5-10 mm 3 range. The total number of white blood cells is often used as indicator of
bacterial and viral infections. For my patients it’s normal.

The red blood cells’ primary function is to carry oxygen in the bloodstream.
RBC 3.48 3.8-5,2 mm3 If the total RBC count is below normal levels, anemia may be present. This
may lead to insufficient supply of oxygen to the body. On the other hand, if
the total RBC count is above normal, polycythemia vera may be present. For
my patients its Normal.

HGB 10.4 13.0-18.8g/dl High hemoglobin levels are usually present among people living in high
altitude levels and among smokers. It’s the body’s compensatory mechanism
in response to low supply of oxygen. On the other hand, low hemoglobin
levels may be present in a variety of blood diseases like sickle cell disease
and thalassemia. For my patient it is low which indicate anemia.

HCT 31.2 40-52% Hematocrit is also known as packed cell volume or PCV. It reflects the
volume percentage of red blood cells in the whole blood. The result is
dependent on the size, structure and total number of red blood cells.
Determining hematocrit is helpful in diagnosing and assessing blood
diseases, nutritional deficiencies and hydration status. For my patient it is
low.

Macrocytic Anemia: When the number is BIGGER than it should be, this
MCV 89 80-96 FL means that the cell is LARGER than normal.

Microcytic Anemia: When the number is SMALLER than normal, the cell
is too SMALL.

MCH 29.9 33-36 g/dL MCH can be used to determine if an anemia is hypo-, normo-, or
hyperchromic. For my patient it is low.

MCHC 33.4 33-36 g/dL MCHC, when increased, can be useful clinically as an indicator of increased
spherocytes (spherocytosis), as in hereditary spherocytosis or autoimmune
hemolytic anemia. It is also increased in homozygous sickle cell or
hemoglobin C disease. For my patients it’s normal.

RDW 13.2 11.5-14.5% One reason for a low RDW level is macrocytic anemia. A high RDW (over
14.5%) means that the red blood cells vary a lot in size. To my patient it’s
normal

Determining platelet count is vital in assessing patients for tendencies of


PLT 380 150-400 bleeding and thrombosis.
High Level: Cancer, allergic reactions, polycythemia vera,1 recent spleen
removal, chronic myelogenous leukemia, inflammation, secondary
thombocytosis.

Low Level: Viral infection, aplastic anemia, leukemia, alcoholism,


vitamin B12 and folic acid deficiency, systemic lupus erythematosus,
hemolytic uremic condition. For my patients it is normal

MPV 7.3 7.5-11.5 fL A low MPV count does increase the risk for serious blood loss if you are
injured. MPV is higher when there is destruction of platelets. For my patient
it is normal.

If a person is sick, and sepsis is suspected, the procalcitonin lab would then
PCT 0.277 0.05- mg/mL be drawn to help determine if an infection is present.

Low levels may indicate that the person's symptoms are due to a cause other
than a bacterial infection, such as a viral infection.

High levels indicate a high probability of sepsis and also suggest a higher
risk of progression to severe sepsis and septic shock. For my patient it is a
bit higher.

PDW 10.3 8.3-25.0 fL Normal PDW indicates platelets that are mostly the same size, while a high
PDW means that platelet size varies greatly, a clue that there may be a
disorder affecting platelets. For my patient it is normal.

URINALYSIS

Urine color Yellow Yellow to dark yellow In visual examination, the urine sample is inspected for color, cloudiness
and odor.
Clear to dark yellow – normal.

Amber to honey yellow – dehydration.

Orange – dehydration, intake of rifampicin, consumption of orange food


dye. For my patient it is normal.

Urine is usually clear but its color may be affected by certain medications
Transparency Clear Clear or cloudy and foods. If cloudiness and unpleasant odor are present, there might be
infection in the urinary tract system. For my patient it’s normal.

Specific gravity reflects how concentrated the urine is. It can measure the
Specific Gravity 1.020 1.005-1.030 proportion of solutes present in the urine when compared to pure water.
Determining specific gravity is useful when you want to detect a particular
substance in the urine sample. For example, if you suspect that a patient
secretes small amounts of protein in the urine, the first morning-void urine
is the best sample because it has high specific gravity and appears
concentrated. For my patient it is normal.

Glucose should not be present in the urine. However, in some circumstances


Glucose Negative (-) Negative the renal threshold allows the excretion of glucose in the urine when the
blood glucose levels are too high. The conditions that can cause glucosuria
are pregnancy, diabetes mellitus, liver diseases and hormonal disorders. For
my patient its normal.

Other types of protein compounds are not detectable in dip stick test and can
Protein Negative (-) Negative or traces be measured through a different urine protein test. Conditions that usually
produce high amounts of protein in the urine include preeclampsia, multiple
myeloma, inflammation, urinary tract injuries, malignancies and other
disorders that destroy red blood cells. For my patients it’s normal.
The pH level of the urine is related to the acid-base balance maintained by
pH 6.5 7.35-7.45 the body. Therefore, consumption of acidic or basic foods as well as the
occurrence of any condition in the body that produces acids or bases will
directly affect the pH of the urine. In some circumstances, too acidic or
basic urine produces crystals. When this phenomenon happens inside the
kidney, kidney stones can develop. For my patient its normal.

Presence of pus cells in urine is a definite indication of some type of


MICROSCOPIC EXAMINATION infection. Pus is a whitish or yellowish or slightly green substance which is
thick like glue. Pus in urine signifies that the body is fighting an infection in
Pus Cells 2.4 0.4 p.v.f the lower or upper urinary tract.

RBCs are present in the urine sample of a person with severe urinary tract
Red Cells 2.4 0.4 p.v.f infection, renal disorders, urinary tract injuries and inflammation. It can also
reflect improper collection of urine specimen (e.g. Urine contaminated by
blood from menstruation or hemorrhoids).

In a normal urine specimen, there are few epithelial cells that can be seen
Epithelial Cells Abundant 0.4 p.v.f under microscopic examination. However, in cases of severe urinary tract
infection, inflammation and malignancies, there will be increased number of
epithelial cells in the urine. Elevated number of epithelial cells can also
signify improper collection of urine specimen, especially if it is not collected
using the midstream-catch technique.

Crystals can be formed from the solutes of the urine especially if the urine
Crystals Negative No crystal present is concentrated or when the pH is too high or too low. Examples of casts that
are not typically present in the urine include leucine, cystine and tyrosine.
These casts may signify malignancies and abnormal metabolic processes.
For my patient it’s normal.
Threads appear as fibers bundled together to form a pale, irregular,
Mucous Threads Moderate No, some longitudinal fragment that is narrow on one end. For my patients its normal.

When the urine is refrigerated, amorphous urates might develop in the


Amorp. Urates Few A few sample. This is detected when the urine is put through a centrifuge, which is
part of the analysis process. Tiny pink pellets will appear during this process.
When the urine is examined under a microscope, these amorphous urates
might appear as particles that are yellow or yellow-brown in color. For my
patients its normal.

If microbes are seen, they are usually reported as "few," "moderate," or


Bacteria Few No "many" present per high power field (HPF). Bacteria from the surrounding
skin can enter the urinary tract at the urethra and move up to the bladder,
causing a urinary tract infection (UTI).
DRUG STUDY
NAME OF DRUG INDICATION ACTION CONTRAINDICATION ADVERSE NURSING
REACTION RESPONSIBILITIES

Generic Name:  Treatment for  Inhibit the DNA  Allergy on  Ataxia  Assess
amebiasis synthesis in hypersensitivity to  Loss of contraindications,
Metromidazole
 Trichomoniasis susceptible any of these drugs coordination allergies.
Brand Name:  Giardiasis protozoa,  Pregnancy  Peripheral  Monitor vital Signs
 Treatment for interfering with  Patient with CNS neuropathy  Examine the skin
Flagyl infections the cells ability to disease  Unpleasant taste for any adverse
Classification: caused by reproduce.  Hepatic disease  Cramps effect.
susceptible  Lactation  Changes in liver
Antiprotozoals protozoa  Never combined function
with alcohol  Superinfection
may occur
Side effects:
Route:
Drug to drug
 Nausea
IVTT interaction:
 Vomiting
 Dizziness  Should not be
 Headache combined with alcohol
Dosage:
 Diarrhea which could cause
severe adverse effect,
500mg/100 ml IV not combined with oral
infusion q6o anticoagulant, can lead
to increase bleeding.

DRUG STUDY
NAME OF DRUG INDICATION ACTION CONTRAINDICATION ADVERSE NURSING
REACTION RESPONSIBILITIES
Generic Name  Broad spectrum  Prevent the  Allergies to  Yeast infection  Monitor for
of cavity bacteria penicillin or  Pain and nephritis
Ampicillin
 Useful switch biosynthesizing cephalosporins inflammation at  Asses for
Brand Name: from parenteral the framework of  Patient with renal the injection site possible
to oral is the cell wall. diseases.  Hypersensitivity contraindications
Ampicillin anticipated  High dose of  Pregnancy reactions may  Monitor VS to
Classification:  For treatment of drug are used to  Lactation include rash, establish baseline
streptococcal treat fever, wheezing. data
Extended spectrum infectious meningococcal  Examine skin for
Pinicillins including meningitis skin rashes
tonsillitis, Drug to drug  Monitor for
Route: pharyngitis interaction: adverse effect.
IVTT infectious. SIDE EFFECT:
 Rat-bite fever If penicillins and
Dosage:  Anthrax  Nausea penicillins resistants
 Vomiting antibiotics are taken
750 mg IVTT q8o
 Diarrhea concurrently with
 Abdominal pain tetracyclines, a decrease
in the effectiveness of
the penicillin result.

DRUG STUDY
NAME OF DRUG INDICATION ACTION CONTRAINDICATION ADVERSE NURSING
REACTION RESPONSIBILITIES
Generic Name:  Relief of  React with the  Contraindicated  Respiratory  Assess history of
moderate to opioid receptors with the depression allergies to any
Tramadol narcotic drug
moderately throughout the following: allergy  Apnea
 focus on vital
Brand Name: severe pain. body to cause to any narcotic  Cardiac arrest
sign
 Limit use in analgesic, agonist  Shock may result  Asses caboratory
Ultram patient with a sedation, or  Diarrhea from narcotic test renal and
Classification:
history of euphoria  Biliary surgery induced liver function
addictions respiratory test.
Narcotics  Chronic pain depression.
 Preoperative Side Effects:
medication
 analgesic  Light headedness
Route: Drug to drug
 Dizziness
interactions:
IVTT  Hallucination
 Pupil  When narcotics
constriction agonists are given with
Dosage:  Impaired mental abrbiturates general
process anesthethics or with
50 mg solution q4o some phenothiazines
and MAOIs, the
likelihood of
respiratory depression,
hypotension.

DRUG STUDY
NAME OF DRUG INDICATION ACTION CONTRAINDICATION ADVERSE NURSING
REACTION RESPONSIBILITIES
Generic Name:  Treatment of  Blocking the  Should not be  GI effects or  Assess for
duodenal ulcer production of used with known diarrhea possible
Ranitidine allergy to any
 Benign prostatic hydrochloric acid  Constipation contraindications,
drugs
Brand Name: ulcer  Short term  Cardiac history of allergy
 Caution during
 GERD treatment of pregnancy arrhythmias  Monitor for
Zantac  active duodenal  adverse effect
Relief of  Lactation Hypotension
Classification: symptom of ulcer or benign  Hepatic or renal  Gynecomastia  Asses for
heartburn gastric ulcer. dysfunction cardiopulmonary
Histamine 2  Acid indigestion  Treatment of status, including
Antagonists  Sour stomach in erosive GERD
Drug to drug
pulse, BP, and
adults the acid benign ECG.
interaction:
regurgitated into  Monitor result of
Route: the esophagus.  Ranitidine, can slow laboratory test.
the metabolism of
IVTT Side Effects:
the following drugs,
 Dizziness leading to increase
 Somnolence serum level and
Dosage:  Confusion possible toxic
reactions: warfarin
50mg IVTT q8o  Hallucinations
anticoagulants,
phenytoin, beta-
adrenergic blockers.

PHYSICAL ASSESSMENT FINDINGS ( 3 Priority System)


Integumentary System Respiratory System Abdomen

Inspection Inspection: Inspection:

 The patient is in comfortable position.  Spine is straight with lateral deviation  Skin is brown
 Skin is brown and intact  Scapula is symmetrical  Size is proportional to the body
 Skin is warm and dry to touch  ICS no bulging or active movement during  The umbilicus is at the midline.
 No lesions or rashes breathing  Presence of 19 stiches due to surgical
Palpation  No masses incision
 No lesions  Presence of slight redness
 No pain felt during palpation.  22 breaths/min  Abdomen is symmetrical bilaterally
 No masses and nodules.  Rhythm is regular Auscultation:
 Edema on the IV site  No use of accessory muscles
Palpation:  Bowel sounds: 17 per minute
Percussion
 Respiratory excursion is normal, symmetrical
movement of the thumb.  Tympany to dullness
 Tactile fremitus is normal, equal bilaterally.  The liver size is 12in
 Vibrations felt in the areas are equal in Palpation
intensity; vibrations are strongest at the top.
Percussion:  Bowel sounds: 16 per minute
No pain felt., no bulges or masses
 Resonant sound is produced during
percussion.
 Rates pain as 7 on a scale of 0-10
Auscultation

 Bronchial sounds heard over the trachea.

USUAL PATTERN INITIAL PATTERN ONGOING PATTERN


I. Health Perception – Health Management
Pattern
 Before hospitalization she described herself  Admitted due to acute pain in the incision site  Vital signs:
as strong and healthy woman.  One day prior to admission she take a bath and  T: 36.5oC
after that the incision started to unpleasant pain  BP: 90/70 mmhg
 She can go to work without any problem
and appear red.  PR: 88 bpm
 She felt pain on her abdomen before she
 RR: 20cpm
hospitalize.
 Sao2: 96 %
 The patient appears more relax this
morning. She verbalizes that she feels a
little better.
II. Nutritional Metabolic Pattern
 Eat 4-5 meals a day including snacks  After the hospitalization, the doctor ordered her  Diet: NPO
 Eat vegetables, rice, fish and meat to eat nothing and her nutrition supply is just  IVF continues to support her electrolytes
from the dextrose fluid
 Drink plenty of water and softdrinks
 Diet: NPO  NGT present on her nasal area. (for
 Drink coffee every morning
drainage of stomach secretion)

III. Elimination  No defecation


 No urinary reported  Urinated 3 times since 4am to 9am (dark
 Urinate 3 times since yesterday when she was yellow urine) about 200ml.
 Bowel movement: every once a day. admitted.  No defecation yet since yesterday.
(constipation occur)

IV. Activity  She stopped working because of the  No activity done


 Work every day as counter checker hospitalization  Patient just lays on bed
 Work from 6:30 to 6:30 pm  She just lay on bed because of the current illness  Can stand up if she feels like to urinate, but
 No day off and work 7 days a week. with assistance.

V. Sleep Pattern  During the hospitalization the patient sleep only  Sleep 3 hours last night which is there is
 Sleep 7 hours at night. one hour. improvement compare from the other night.
 Sleep around 9pm and wake up 4 or 5 am in  On and off sleep during day time.
the morning.

 No problem in hearing and vision, sense of


VI. Cognitive Perceptual Pattern
 Educational attainment is high school  Cannot do anything because of the smell and touch.

graduate. hospitalization.
 Has a good eyesight and hearing  No problem in hearing and vision.
 She is responsive.  Vital Signs
 T: 38.1oC
 BP: 110/70 mmhg
 PR:111 bpm
 RR: 25 cpm
VII. Self-Perception Self Concept Pattern  SaO2: 97%
 The client verbalize that before
 She is looking forward to getting better, so
hospitalization she was healthy and can
that she can go home and see her 2 kids.
accept and tolerate stress.  Worried about her kids.
 Concern about her life and how she starts
again after hospitalization.

VIII. Role Relationship Pattern


 Before hospitalization she have personal  Still thinking the cause of her hospitalization.  Her mother look after her since her
problem with her live-in partner. hospitalization but sometimes her partner
also visits her. She misses her kids.

IX. Sexuality
 Use of birth control pills
 Sexually active  During hospitalization she stop taking the birth  No plan for another child.
 She have 2 kids control pills.  May use contraceptives technique again to
 2 little boys and 1 two years old. avoid pregnancy.

X. Coping
 Patient thinking about her family and the
problem with her live-in partner.  She verbalized she can do everything now  Looking forward to start over again, live
because everything is stopped when she is being happily even if she losses her job.
hospitalized.

XI. Value Belief Pattern


 Go to church if she have extra time on
Sunday.  Prays to the God she’ll get well soon and go  She prays every day for guidance and
 Religion is Roman Catholic home protection from God.
 Roman Catholic but no much time to attend
church.

NURSING CARE PLAN


OBJECTIVES OF
CARE
CUES and NURSING INTERVENTION RATIONALE EVALUATION
EVIDENCES DIAGNOSIS

Subjective: Impaired skin integrity After my 5 hours of  Determine if the  Affect healing After my 5 hours of duty
related to surgery nursing intervention the incision is acute time and the and nursing intervention
“Na infection ako ang patient will display the patient demonstrates
injury from clients emotional
tiyan maong nibalik ko positive attitude how she
timely healing of skin surgery and physical
sa doctor” take care of her skin
lesions and wounds response especially the area of
As verbalized by the without complications as  Determine the  To clarify incision, as evidenced of:
patient evidenced of: clients intervention
discomfort needs and priority  Skin temperature
 To improved decreased from
 Skin temp. will 30.10C to 36.50C
 Instruct the client circulation
Objective: be at 36.0 0C  Redness of skin is
in good skin  To avoid further lessen
from 38.10C
V/S Taken: hygiene infection  Swelling is
 The redness on
 Encourage the minimized
Temp. : 38.10C skin will be
client to keep the
minimize
PR:111 bpm wound dry
 Swelling will be
RR: 25 cpm control  For wound and
 Use appropriate healing meet
BP: 110/70 mmHg
dressing needs of client
 Skin warm to
touch
 Redness on  To give proper
incision site medication for
infection
 Swelling on the  Refer to the
site of incision doctor if  To avoid further
infection is damage and
severe infection

COLLABORATIVE:

 Administer
antibiotics for
infection as
prescribed by the
phycisian
NURSING CARE PLAN
CUES and NURSING OBJECTIVES OF INTERVENTION RATIONALE EVALUATION
EVIDENCES DIAGNOSIS CARE
Imbalance nutrition less After 5 hours of my duty After my 5 hours of duty
than body requirements and nursing interventions  Observe for  Indicate protein and nursing intervention
Subjective: the client will verbalize subcutaneous fat energy the patient the patient
“Bawalan ko mukaon ug the understanding of and muscle malnutrition verbalized that she can
bisag unsa ana ang causative factors when wasting  To evaluate the not take food by mouth,
doctor” known and necessary  Review indicated normal as evidenced of:
As verbalized by the intervention as laboratory data electrolytes
patient evidenced of: imbalances  Patient never
 Evaluate total  Helps determine complain even if
 Pt will doctors fluid intake nutritional needs she can not eat
Objective: order on her NPO  Communicate  To alleviate by mouth
Temp.: 38.10C diet with pt for any anxiety  Patient knew
PR: 111 bpm  Understanding other concerns what is the
RR: 25 cpm causes why she  Document all the  To provide underlying cause
BP: 110/70 mmHg can’t take food subjective cues baseline data why she can not
by mouth by the pt intake food
 Pt appear weak  Refer to the  For proper advice
 Pale skin doctor for any and intervention
 Poor skin turgor further concern
 NPO diet
NURSING CARE PLAN
OBJECTIVES OF
CARE
CUES and NURSING INTERVENTION RATIONALE EVALUATION
EVIDENCES DIAGNOSIS

Pain related to post At the end of my 5 hours  Assess the site of  Surgical incision After my 5 hours of duty
surgical procedure of duty and nursing incision for any is the and nursing interventions
Subjective: intervention the pt will the patient reported that
sign of infection precipitating
the pain relieved as
“Sakit akong tahi tungod report the relieve or the  Assess the level factors of pain
evidence of:
sa operasyon” pain will be control as of pain by scaling  To determine
evidenced of: it from 0 to 10 how severe is the  Pain scale
As verbalized by the  Note the location pain reduced from 7 to
patient of surgical  Diagonal 3 out 10
 Pain scale will  Pt face is more
Objective: incision incisions are
reduce from 7 to relax and she
 Obtain clients more painful than
3 out of 10 even smile at me
V/S Taken: assessment of transverse
 The face will  Heart rate
pain to include  In order to fully decreased from
Temp. : 38.10C have relax
location, understand 111 bpm to 88
appearance
PR: 111bpm characteristics, clients pain bpm
 The rapid heart  Respiratory rate
onset, duration, symptoms
beat will be at decreased from
RR: 25cpm frequency,  Observations
least in normal 25 cpm to 20 cpm
quality, & may not be
BP: 110/70 range
intensity congruent with
 Respiratory rate Goal partially met
 Pain scale of 7  Observe non- verbal reports or
will be at normal
out of 10 verbal cues and may be only
range
Face grimacing pain behaviors indication present
when client is
 Swelling on the unable to
site of incision verbalize
COLLABORATIVE:
 Redness of the
skin on incision  Administer pain
site medication as  To alleviate pain
prescribed by the and promote
doctor relaxation
SUMMARY OF NURSING DIANOSIS

Impaired skin integrity related to surgical incision on the right lower quadrant secondary to the disease condition.

Acute pain related to distension of intestinal tissues by inflammation.

Imbalanced nutrition: less than body requirement related to vomiting and impaired digestion.
ANNOTATED READINGS
Pancreatitis is an acute or chronic inflammation of the pancreas. Acute attacks are often characterized by severe abdominal pain that radiates from the upper belly
through to the back and can cause effects ranging from mild pancreatic swelling to life-threatening failure of many organs. Chronic pancreatitis is a progressive
condition that results in permanent damage of pancreatic tissue. Recurrent acute attacks can lead to chronic pancreatitis.
The pancreas is a narrow, flat organ located deep in the abdominal cavity, behind the stomach and below the liver. It has head, middle, and tail sections. Its head
section connects to the duodenum, the first part of the small intestine. Inside the pancreas, small ducts (tubes) feed digestive enzymes produced by the pancreas into
the pancreatic duct. This large duct carries the digestive enzymes down the length of the pancreas, from the tail to the head section, and into the duodenum. The
common bile duct also runs through the head section of the pancreas, carrying bile from the liver and gallbladder into the small intestine. The bile duct and
pancreatic duct usually join just before entering the duodenum and share a common opening into the small intestine.
The pancreas has two kinds of tissues: exocrine and endocrine. Exocrine tissues make powerful enzymes that help digest fats, proteins, and carbohydrates in the
small intestine as well as make bicarbonate that helps neutralize stomach acids. Endocrine tissues have "islets" or clusters of certain cell types that produce
the hormones insulin and glucagon (among other hormones), whihch are vital for the transportation of glucose into the body's cells and for maintaining normal
blood levels of glucose (blood sugar).

The cells of the exocrine pancreas make, store, and release digestive enzymes. Many of these digestive enzymes are inactive within the cell but activated when they
reach the small intestine. Obstruction of the common bile and pancreatic ducts, most commonly by gallstones, causes an accumulation and early activation of
digestive enzymes, leading to pancreatic damage and pancreatitis.

Pancreatitis can also occur without the presence of an obstruction. In addition to the normal stress on pancreatic cells and genetic differences between individuals,
external stressors such as alcoholism affect regular pancreatic cell function. The stress may not be sufficient to cause pancreatitis in all individuals, but in certain
people, it appears to substantially increase the risk by adversely affecting normal digestive enzyme synthesis and release or by causing early activation of these
enzymes. The resulting cell damage leads to cell death and, if the damaging events and inflammatory response are too great or persistent, pancreatitis may develop.
Pancreatitis occurs more frequently in men than in women and is known to be linked to and aggravated by alcoholism and gallbladder disease. In the latter case, this
happens because of obstruction of the common duct from the gallbladder and pancreas into the intestine. Obstruction is most frequently due to gallstones and
sometimes to biliary sludge. Alcoholism and gallbladder disease are responsible for about 80% of acute pancreatitis attacks and figure prominently in chronic
pancreatitis.
Another 10% of the time the cause is idiopathic, and the other 10% of the time it is due to one of the following:

 Drugs such as valproic acid and estrogen

 Viral infections such as mumps, Epstein-Barr, and hepatitis A, B and E


 Exceedingly high blood triglyceride level, hyperparathyroidism, or high blood calcium level
 Cystic fibrosis and inherited defects that result in early activation of digestive enzymes
 Pancreatic cancer
 Autoimmunity
 Surgery in the area of the pancreas (such as bile duct surgery)

 Trauma to the abdomen ("blunt trauma")


CONCLUSION

Injury to the pancreas after blunt abdominal trauma is less frequent than that of other solid organs, such as the liver and spleen. Pancreatic injuries occur in
less than 2% of all patients with abdominal trauma. Penetrating injuries are three to four times more common than blunt injuries. Pancreatic injuries are usually
associated with injuries to adjacent organ and major vascular structure. Mortality due to blunt trauma is about 15-50%. Mostly death results from the hemorrhage
from nearby vascular structures. second most common cause of death is delayed mortality from intra-abdominal sepsis. Frequently noted in the history in traumatic
pancreatitis is impact of the epigastric area of the patient with the steering wheel of a car in head-on collision. Cyclists involved in accidents are peculiarly liable to
pancreatic injury, the blow to the abdomen being delivered by the handlebars or direct blow by assault. Pancreatic contusion is generally believed to involve rupture
of minor or major components of the duct apparatus with consequent effects due to activity of liberated enzymes.

The area of the pancreas most likely to be damaged as a result of a blow or crushing force is that which overlies the vertebrae . Although the middle segment
of the pancreas is the most vulnerable, injuries of the head and
the tail do occur. Typical mode of trauma is the clue and high index of suspicion is required to diagnose the pancreatic injury . They present with mild epigastric pain,
abdominal tenderness or other non-specific abdominal findings. Investigations will show increased hematocrit, Increased Total Leukocyte Count, absent psoas shadow
in plain x-ray abdomen. Serum amylase has been claimed to be neither sensitive nor specific in the diagnosis of pancreatic injury . Serum amylase is increased in 90%
case of pancreatic trauma . Even if elevated, there is no correlation to the severity of the injury. Contrast-enhanced computerized tomography (CE-CT) has been used
to predict the severity of an attack of acute pancreatitis.

The presence of gas within an area of necrosis shown by CE-CT is highly suggestive of infection. Management: The management of patients with blunt
pancreatic injuries should be individualized. Selected patients with stable abdominal signs without pancreatic ductal injuries may be carefully observed. Any
deterioration of clinical situation or demonstration of pancreatic ductal injury should mandate an exploratory laparotomy. The treatment has to be tailored to individual
situations especially in patients with severe concomitant injuries.
Foundation University
COLLEGE OF NURSING
Dumaguete City

BIBLIOGRAPHY
INTERNET:
ISOLATED PANCREATIC INJURY FOLLOWING BLUNT TRAUMA ABDOMEN (PDF Download Available). Available from:
https://www.researchgate.net/publication/276026806_ISOLATED_PANCREATIC_INJURY_FOLLOWING_BLUNT_TRAUMA_ABDOMEN [accessed Sep 16,
2017].

Acute pancreatitis: A literature review. Available from: https://www.researchgate.net/publication/26328843_Acute_pancreatitis_A_literature_review [accessed Sep


16, 2017].

https://labtestsonline.org/understanding/conditions/pancreatitis [access on September 24, 2017]

BOOK:

Bunner and Suddarth, Medical-Surgical of Nursing 12th Edition.

Carol Mattson Porth, Essentials of Pathophysiology 3rd Edition

Kozier & Erb's Fundamentals of Nursing 10th Edition

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